Provider Demographics
NPI:1912944737
Name:SCADDAN, PAUL BLAKELY (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:BLAKELY
Last Name:SCADDAN
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 1:616 UNIONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SEBEWAING
Mailing Address - State:MI
Mailing Address - Zip Code:48759-1631
Mailing Address - Country:US
Mailing Address - Phone:989-883-9088
Mailing Address - Fax:
Practice Address - Street 1:616 UNIONVILLE RD
Practice Address - Street 2:
Practice Address - City:SEBEWAING
Practice Address - State:MI
Practice Address - Zip Code:48759-1631
Practice Address - Country:US
Practice Address - Phone:989-883-9088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076874207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI142056OtherGLHP SHN NUMBER
MI4543406Medicaid
MI142056OtherGLHP SHN NUMBER
MI0C26012045Medicare PIN
MI0C26017014Medicare PIN
MI4543406Medicaid
MI4523646Medicaid