Provider Demographics
NPI:1932635562
Name:SCANLON, COURTNEY L (MD, MBA)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:L
Last Name:SCANLON
Suffix:
Gender:F
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 POND AVE APT 1107
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-7115
Mailing Address - Country:US
Mailing Address - Phone:401-578-2941
Mailing Address - Fax:
Practice Address - Street 1:301 S HUNTINGTON AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-4807
Practice Address - Country:US
Practice Address - Phone:857-307-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-02
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA283045207Q00000X
RIMD18765207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine