Provider Demographics
NPI:1215901046
Name:MCCOLLUM, JEFFREY SCOTT (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:SCOTT
Last Name:MCCOLLUM
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 1:100 S TEBO ST
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:MO
Mailing Address - Zip Code:65360-1161
Mailing Address - Country:US
Mailing Address - Phone:660-647-2147
Mailing Address - Fax:660-890-8496
Practice Address - Street 1:100 S TEBO ST
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:MO
Practice Address - Zip Code:65360-1161
Practice Address - Country:US
Practice Address - Phone:660-647-2147
Practice Address - Fax:660-890-8496
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23869207P00000X, 207Q00000X
MO2013030577207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200031730AMedicaid
OKOK403075Medicare PIN
OK243428002Medicare ID - Type Unspecified
F36457Medicare UPIN