Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0204X | Pediatric Emergency Doctor | 046445 | GA |
N | 2080P0204X | Pediatric Emergency Doctor | 4928357-1205 | UT |
NPI | 1003870288 |
---|---|
Provider Name | Michael Mallory |
First Address | Atlanta, GA 30345-4149 |
Second Address | Atlanta, GA 30342-1605 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/04/2006 |
Last Update Date | 06/11/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
G50878 | (02) |