Healthcare Provider Details

I. General information

NPI: 1710409842
Provider Name (Legal Business Name): TAHA RASHID MALLICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2017
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MEDICAL CENTER DR
HAZARD KY
41701-9466
US

IV. Provider business mailing address

200 MEDICAL CENTER DR
HAZARD KY
41701-9466
US

V. Phone/Fax

Practice location:
  • Phone: 606-487-7510
  • Fax: 606-439-6793
Mailing address:
  • Phone: 606-487-7510
  • Fax: 606-439-6793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number56797
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: