Healthcare Provider Details

I. General information

NPI: 1659341667
Provider Name (Legal Business Name): ALAN H MALLACE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 10/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18444 N 25TH AVE STE 310
PHOENIX AZ
85023-1266
US

IV. Provider business mailing address

10474 W THUNDERBIRD BLVD SUITE 200
SUN CITY AZ
85351-3015
US

V. Phone/Fax

Practice location:
  • Phone: 866-974-2673
  • Fax: 866-939-2673
Mailing address:
  • Phone: 866-974-2673
  • Fax: 866-939-2673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number9569
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number9569
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number09569
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: