Provider Demographics
NPI:1104353804
Name:SCANLON, SHANE JEREMY (DO)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:JEREMY
Last Name:SCANLON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 MACK BLVD
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-5622
Mailing Address - Country:US
Mailing Address - Phone:610-395-0307
Mailing Address - Fax:610-395-0950
Practice Address - Street 1:250 CETRONIA RD STE 115
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104-9168
Practice Address - Country:US
Practice Address - Phone:610-395-0307
Practice Address - Fax:610-395-0950
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-12
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS020553207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine