Provider Demographics
NPI:1356440234
Name:SCANLON, PATRICK H JR (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:H
Last Name:SCANLON
Suffix:JR
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 1:971 LAKELAND DR STE 1460
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4621
Mailing Address - Country:US
Mailing Address - Phone:601-982-3202
Mailing Address - Fax:601-982-3259
Practice Address - Street 1:971 LAKELAND DR STE 1460
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4621
Practice Address - Country:US
Practice Address - Phone:601-982-3202
Practice Address - Fax:601-982-3259
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16216174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
G31207Medicare UPIN