Healthcare Provider Details

I. General information

NPI: 1447702154
Provider Name (Legal Business Name): JERRY C MALLORY JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2016
Last Update Date: 10/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4018 BAYARD 44121
APO AA
44121
US

IV. Provider business mailing address

4018 BAYARD 4018 BAYARD
CLEVELAND OH
44121
US

V. Phone/Fax

Practice location:
  • Phone: 216-533-0094
  • Fax:
Mailing address:
  • Phone: 216-533-0094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: