1033393996 NPI number — JARED EMERSON MALLALIEU D.O.

Table of content: JARED EMERSON MALLALIEU D.O. (NPI 1033393996)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033393996 NPI number — JARED EMERSON MALLALIEU D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALLALIEU
Provider First Name:
JARED
Provider Middle Name:
EMERSON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1033393996
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10845 PHILADELPHIA RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITE MARSH
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21162-1717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-335-0008
Provider Business Mailing Address Fax Number:
410-335-3113

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
484 RITCHIE HWY STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SEVERNA PARK
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21146-2961
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-544-4600
Provider Business Practice Location Address Fax Number:
410-544-0997
Provider Enumeration Date:
12/27/2007

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: 208600000X , with the licence number:  H68311 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 95050303 . This is a "CAREFIRST" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 417363500 . This is a "MEDICAL ASSISTANCE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 1622382ZF69 . This is a "MEDICARE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 242301 . This is a "JHHC" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: U993 0001 . This is a "CAREFIRST" identifier , issued by the state of ( DC ) . This identifiers is of the category "OTHER".




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