1710086608 NPI number — MR. NORMAN ROBERT MALLORY PA-C

Table of content: MR. NORMAN ROBERT MALLORY PA-C (NPI 1710086608)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710086608 NPI number — MR. NORMAN ROBERT MALLORY PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALLORY
Provider First Name:
NORMAN
Provider Middle Name:
ROBERT
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710086608
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
C/O ST MARYS HEALTH SYSTEM - PROVIDER ENROLLMENT
Provider Second Line Business Mailing Address:
PO BOX 7291
Provider Business Mailing Address City Name:
LEWISTON
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04243-7291
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-777-8941
Provider Business Mailing Address Fax Number:
207-777-4397

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
360 BROADWAY STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BANGOR
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04401-3979
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-907-3550
Provider Business Practice Location Address Fax Number:
207-907-3562
Provider Enumeration Date:
09/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA-692 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com