Provider Demographics
NPI:1619077484
Name:SCAL, PETER BENJAMIN (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:BENJAMIN
Last Name:SCAL
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 1:720 WASHINGTON AVE SE STE 300
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-2904
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2512 S 7TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1404
Practice Address - Country:US
Practice Address - Phone:612-365-6777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN40605208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN136416OtherFAIRVIEW
SD7777470Medicaid
MN1025762OtherPREFERRED ONE
MT0060411Medicaid
ND10387Medicaid
MN1163348OtherARAZ
MNHP31785OtherHEALTH PARTNERS
MN12-00978OtherMEDICA CHOICE
MN12-09026OtherMEDICA PRIMARY
MN151276OtherUCARE
MN764415900Medicaid
IA0535047Medicaid
MN025A6SCOtherBLUE CROSS BLUE SHIELD
WI34044700Medicaid