Provider Demographics
NPI:1215080395
Name:ROUSTIO, SCOTT R (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:R
Last Name:ROUSTIO
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 1:8422 BRAESWOOD ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-4235
Mailing Address - Country:US
Mailing Address - Phone:618-624-0091
Mailing Address - Fax:
Practice Address - Street 1:8422 BRAESWOOD ESTATES DR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-4235
Practice Address - Country:US
Practice Address - Phone:618-624-0091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-087697207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF41093Medicare UPIN