Provider Demographics
NPI:1487729430
Name:JOHN D SCALA MD PC
Entity type:Organization
Organization Name:JOHN D SCALA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:SCALA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-634-4099
Mailing Address - Street 1:PO BOX 829
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-0829
Mailing Address - Country:US
Mailing Address - Phone:815-634-4099
Mailing Address - Fax:815-634-4052
Practice Address - Street 1:460 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:COAL CITY
Practice Address - State:IL
Practice Address - Zip Code:60416-1045
Practice Address - Country:US
Practice Address - Phone:815-634-4099
Practice Address - Fax:815-634-4052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILDC7531OtherRAILROAD MEDICARE
IL03232018OtherBCBS PROVIDER ID
IL03232018OtherBCBS PROVIDER ID
ILDC7531Medicare PIN