Healthcare Provider Details

I. General information

NPI: 1669529954
Provider Name (Legal Business Name): MICHAEL SCANLON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 11/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

162 MANSFIELD AVE # A
WILLIMANTIC CT
06226-2041
US

IV. Provider business mailing address

196 PARKWAY S SUITE 304
WATERFORD CT
06385-1234
US

V. Phone/Fax

Practice location:
  • Phone: 860-456-4250
  • Fax:
Mailing address:
  • Phone: 486-044-2702
  • Fax: 860-444-0074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHAEL JAMES SCANLON
Title or Position: PHYSICIAN/OWNER
Credential: DPM
Phone: 860-657-3668