1114999430 NPI number — LATISHA M MALCOM M.D.

Table of content: LATISHA M MALCOM M.D. (NPI 1114999430)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114999430 NPI number — LATISHA M MALCOM M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALCOM
Provider First Name:
LATISHA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1114999430
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/12/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28801 PLYMOUTH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIVONIA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48150-2385
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-266-2780
Provider Business Mailing Address Fax Number:
734-466-9615

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6455 GRATIOT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48207-1808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-921-8600
Provider Business Practice Location Address Fax Number:
313-921-1712
Provider Enumeration Date:
02/02/2006

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: 207R00000X , with the licence number:  4301070929 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4604232-10 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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