Provider Demographics
NPI:1700340106
Name:SCALISE, ROBERT CHRISTOPHER (DO)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:CHRISTOPHER
Last Name:SCALISE
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 1:1 WAHOO DRIVE
Mailing Address - Street 2:MEDICAL CLINIC, OCCUPATIONAL HEALTH
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06349
Mailing Address - Country:US
Mailing Address - Phone:860-694-4910
Mailing Address - Fax:
Practice Address - Street 1:59 SEQUIN DR
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-5510
Practice Address - Country:US
Practice Address - Phone:619-882-9148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-30
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101018005171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5101018005OtherMICHIGAN STATE MEDICAL LICENSE