Basic Information
| Provider Information | |||||||||
| NPI: | 1609874197 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCANLON | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | |||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 407 | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304750407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125374986 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1811 EDWINA DR | ||||||||
| Address2: | |||||||||
| City: | VIDALIA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 304748963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9125388105 | ||||||||
| FaxNumber: | 9125388109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2005 | ||||||||
| LastUpdateDate: | 10/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 65886 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 65886 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | P2754298 | 01 | OXFORD | OTHER | 003107027A | 05 | GA | MEDICAID | 9392179 | 01 | CIGNA | OTHER | 2K3975 | 01 | HEALTHNET | OTHER | 3263210 | 01 | AETNA | OTHER |