Provider Demographics
NPI:1972545465
Name:SCANLAN, KATHLEEN M (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:SCANLAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5189
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:12273 W MCMILLAN RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-0555
Practice Address - Country:US
Practice Address - Phone:208-367-6330
Practice Address - Fax:208-367-4765
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM7309207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003922300Medicaid
G62937Medicare UPIN
ID1138548Medicare ID - Type Unspecified