Basic Information
| Provider Information | |||||||||
| NPI: | 1396808960 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCALLON | ||||||||
| FirstName: | COSETTE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | ISU THOMAS B THIELEN STUDENT HEALTH CENTER | ||||||||
| Address2: | UNION & SHELDON | ||||||||
| City: | AMES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500112260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152945801 | ||||||||
| FaxNumber: | 5152947180 | ||||||||
| Practice Location | |||||||||
| Address1: | ISU THOMAS B THIELEN STUDENT HEALTH CENTER | ||||||||
| Address2: | UNION & SHELDON | ||||||||
| City: | AMES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500112260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152945801 | ||||||||
| FaxNumber: | 5152947180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 26458 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02717 | 01 | IA | BCBS | OTHER | 0051268 | 05 | IA | MEDICAID |