Provider Demographics
NPI:1609874197
Name:SCANLON, ROBERT (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:SCANLON
Suffix:
Gender:M
Credentials:DO
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 407
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-0407
Mailing Address - Country:US
Mailing Address - Phone:912-537-4986
Mailing Address - Fax:
Practice Address - Street 1:1811 EDWINA DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8963
Practice Address - Country:US
Practice Address - Phone:912-538-8105
Practice Address - Fax:912-538-8109
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA65886207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P2754298OtherOXFORD
GA003107027AMedicaid
9392179OtherCIGNA
2K3975OtherHEALTHNET
3263210OtherAETNA
2K3975OtherHEALTHNET
2K3975OtherHEALTHNET