1114119302 NPI number — RAYMOND W. SCALLEN, MD PLC

Table of content: (NPI 1114119302)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114119302 NPI number — RAYMOND W. SCALLEN, MD PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RAYMOND W. SCALLEN, MD PLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114119302
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7801 EAST BUSH LAKE ROAD
Provider Second Line Business Mailing Address:
SUITE 320
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55439
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-831-5773
Provider Business Mailing Address Fax Number:
952-831-7224

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2545 CHICAGO AVE.
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-863-6025
Provider Business Practice Location Address Fax Number:
612-863-7790
Provider Enumeration Date:
08/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SCALLEN
Authorized Official First Name:
RAYMOND
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
MD/OWNER
Authorized Official Telephone Number:
612-863-6025

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  12424 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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