Provider Demographics
NPI:1073582623
Name:SCANLON, JOHN CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CHARLES
Last Name:SCANLON
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 5545
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5545
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:
Practice Address - Street 1:1500 SALEM ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2164
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:765-448-7631
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01023751A207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100231140Medicaid
IN000000191108OtherANTHEM PROVIDER NUMBER
IN10825885OtherCAQH NUMBER
INSC80461029Medicaid
IN9397438OtherPHCS PID NUMBER
IN000000191108OtherANTHEM PROVIDER NUMBER
IN815450XMedicare PIN
IN10825885OtherCAQH NUMBER
IN815490TMedicare PIN
IN810000511Medicare PIN