Basic Information
Provider Information | |||||||||
NPI: | 1720086747 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOLDEN | ||||||||
FirstName: | C | ||||||||
MiddleName: | SCOTT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 530 VANCE RD | ||||||||
Address2: |   | ||||||||
City: | VALLEY PARK | ||||||||
State: | MO | ||||||||
PostalCode: | 630881527 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6362255445 | ||||||||
FaxNumber: | 6362255552 | ||||||||
Practice Location | |||||||||
Address1: | 555 N NEW BALLAS RD | ||||||||
Address2: | SUITE 110 | ||||||||
City: | SAINT LOUIS | ||||||||
State: | MO | ||||||||
PostalCode: | 631416825 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6362255445 | ||||||||
FaxNumber: | 3144326308 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/13/2005 | ||||||||
LastUpdateDate: | 08/28/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | R7574 | MO | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 110042155 | 01 | MO | RR MEDICARE | OTHER | 101330 | 01 | MO | HEALTHLINK | OTHER | 51321 | 01 | MO | GROUP HEALTH PLAN | OTHER | 20962 | 01 | MO | BLUE CROSS/BLUE SHIELD | OTHER |