Healthcare Provider Details

I. General information

NPI: 1154397685
Provider Name (Legal Business Name): MALLORY T HARLING MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 03/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 E VALLEY RD STE 105
BASALT CO
81621-8352
US

IV. Provider business mailing address

1450 E VALLEY RD STE 105
BASALT CO
81621-8352
US

V. Phone/Fax

Practice location:
  • Phone: 970-927-1717
  • Fax: 970-927-6164
Mailing address:
  • Phone: 970-927-1717
  • Fax: 970-927-6164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number16141
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number16141
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1609842145
Identifier TypeOTHER
Identifier State
Identifier IssuerGROUP NPI
# 2
Identifier201467647
Identifier TypeOTHER
Identifier State
Identifier IssuerTAX ID
# 3
Identifier01161413
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: