Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207QA0401X | Family Doctor - Addiction Medicine | 17663 | KS |
Y | 207QA0401X | Family Doctor - Addiction Medicine | 20245 | MN |
NPI | 1528054301 |
---|---|
Provider Name | Timothy M Scanlan |
First Address | Hugo, MN 55038-6060 |
Second Address | Hugo, MN 55038-6060 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/09/2005 |
Last Update Date | 27/11/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
B91108 | (02) | MN |