Provider Demographics
NPI:1003899089
Name:SCALLON, STEPHEN MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:MARK
Last Name:SCALLON
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 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:651-439-1234
Mailing Address - Fax:
Practice Address - Street 1:1500 CURVE CREST BLVD W
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6040
Practice Address - Country:US
Practice Address - Phone:651-439-1234
Practice Address - Fax:651-439-1547
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI24613208000000X
MN29155208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN179773500Medicaid
WI30626700Medicaid
MN179773500Medicaid
MN370002990Medicare PIN
WI001256150Medicare PIN