Provider Demographics
NPI:1720130156
Name:SCALLAN, PERRY J SR (MDFACP)
Entity type:Individual
Prefix:DR
First Name:PERRY
Middle Name:J
Last Name:SCALLAN
Suffix:SR
Gender:M
Credentials:MDFACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 GAINESVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-4512
Mailing Address - Country:US
Mailing Address - Phone:706-781-1600
Mailing Address - Fax:706-835-2794
Practice Address - Street 1:204 GAINESVILLE HWY
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-4512
Practice Address - Country:US
Practice Address - Phone:706-781-1600
Practice Address - Fax:706-835-2794
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033190174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA010682127OtherTAX ID NUMBER
GA010682127OtherTAX ID NUMBER