1417155284 NPI number — STEPHEN M MALOFF MD PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417155284 NPI number — STEPHEN M MALOFF MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEPHEN M MALOFF MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1417155284
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4948
Provider Second Line Business Mailing Address:
1950 E CLARK STREET SUITE A
Provider Business Mailing Address City Name:
POCATELLO
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-232-5550
Provider Business Mailing Address Fax Number:
208-232-5553

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1950 E CLARK STREET
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
POCATELLO
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-232-5550
Provider Business Practice Location Address Fax Number:
208-232-5553
Provider Enumeration Date:
07/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MALOFF
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
208-232-5550

Provider Taxonomy Codes

  • Taxonomy code: 2082S0099X , with the licence number:  M3508 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: D03833100 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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