Healthcare Provider Details

I. General information

NPI: 1487729430
Provider Name (Legal Business Name): JOHN D SCALA MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 01/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 N BROADWAY ST
COAL CITY IL
60416-1045
US

IV. Provider business mailing address

PO BOX 829
MORRIS IL
60450-0829
US

V. Phone/Fax

Practice location:
  • Phone: 815-634-4099
  • Fax: 815-634-4052
Mailing address:
  • Phone: 815-634-4099
  • Fax: 815-634-4052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: JOHN D SCALA
Title or Position: PRESIDENT
Credential: MD
Phone: 815-634-4099