Provider Demographics
NPI:1275534109
Name:SCANLAN, MICHELLE C (MD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:C
Last Name:SCANLAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4410 MEDICAL DR
Mailing Address - Street 2:STE 100
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-6306
Mailing Address - Country:US
Mailing Address - Phone:210-614-4000
Mailing Address - Fax:210-614-9114
Practice Address - Street 1:4410 MEDICAL DR
Practice Address - Street 2:STE 100
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-6306
Practice Address - Country:US
Practice Address - Phone:210-614-4000
Practice Address - Fax:210-614-9114
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3936207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX046653401Medicaid
110231816OtherRAILROAD MEDICARE
TX046653401Medicaid
G68327Medicare UPIN