1619451010 NPI number — MRS. MAXINE LORRAINE MALCOLM RN

Table of content: MRS. MAXINE LORRAINE MALCOLM RN (NPI 1619451010)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619451010 NPI number — MRS. MAXINE LORRAINE MALCOLM RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALCOLM
Provider First Name:
MAXINE
Provider Middle Name:
LORRAINE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HALL
Provider Other First Name:
MAXINE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MAXINE MALCOLM
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1619451010
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
440 SIXTH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PELHAM
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10803-1202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
646-209-5163
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4462 PARK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10457-2438
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-582-9100
Provider Business Practice Location Address Fax Number:
212-956-0526
Provider Enumeration Date:
09/20/2018

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: 163W00000X , with the licence number:  661248-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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