Provider Demographics
NPI:1154597011
Name:KECKLER, SCOTT JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:JAMES
Last Name:KECKLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:1600 W 22ND ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1521
Practice Address - Country:US
Practice Address - Phone:605-312-1000
Practice Address - Fax:605-312-1001
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012024116208600000X
SD116152086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431560263OtherTRICARE
AR193951001Medicaid
MOP01089889OtherRR MCR
MO1154597011Medicaid
MO132680330Medicare PIN