Provider Demographics
NPI:1528054301
Name:SCANLAN, TIMOTHY M (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:M
Last Name:SCANLAN
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 1:4767 DAHLIA WAY N
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:MN
Mailing Address - Zip Code:55038-6060
Mailing Address - Country:US
Mailing Address - Phone:651-493-4856
Mailing Address - Fax:
Practice Address - Street 1:4767 DAHLIA WAY N
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:MN
Practice Address - Zip Code:55038-6060
Practice Address - Country:US
Practice Address - Phone:651-493-4856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17663207QA0401X
MN20245207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNB91108Medicare UPIN