Healthcare Provider Details

I. General information

NPI: 1164774923
Provider Name (Legal Business Name): SM MALOFF MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2012
Last Update Date: 10/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 VISTA DR
POCATELLO ID
83201-4987
US

IV. Provider business mailing address

444 HOSPITAL WAY STE 477
POCATELLO ID
83201-2744
US

V. Phone/Fax

Practice location:
  • Phone: 208-239-0380
  • Fax: 208-233-6983
Mailing address:
  • Phone: 208-239-0380
  • Fax: 208-233-6983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License NumberM 3508
License Number StateID

VIII. Authorized Official

Name: STEPHEN M MALOFF
Title or Position: OWNER
Credential: MD
Phone: 208-239-0380