Provider Demographics
NPI:1114119302
Name:RAYMOND W. SCALLEN, MD PLC
Entity Type:Organization
Organization Name:RAYMOND W. SCALLEN, MD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:W
Authorized Official - Last Name:SCALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-863-6025
Mailing Address - Street 1:7801 EAST BUSH LAKE ROAD
Mailing Address - Street 2:SUITE 320
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55439
Mailing Address - Country:US
Mailing Address - Phone:952-831-5773
Mailing Address - Fax:952-831-7224
Practice Address - Street 1:2545 CHICAGO AVE.
Practice Address - Street 2:SUITE 500
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404
Practice Address - Country:US
Practice Address - Phone:612-863-6025
Practice Address - Fax:612-863-7790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-13
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12424174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty