Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213EP1101X | Primary Podiatric Medicine | 5901001813 | MI |
NPI | 1548385156 |
---|---|
Provider Name | Paul Mallamo |
First Address | Chesterfield, MI 48047-3514 |
Second Address | Chesterfield, MI 48047-3514 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/03/2007 |
Last Update Date | 28/07/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
4253362 | (05) | MI |
480030776 | RAILROAD MEDICARE (01) | MI |
U67117 | (02) | MI |