Healthcare Provider Details

I. General information

NPI: 1053542985
Provider Name (Legal Business Name): JARED MALLALIEU, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2009
Last Update Date: 08/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

484 RITCHIE HWY SUITE A
SEVERNA PARK MD
21146-2961
US

IV. Provider business mailing address

10845 PHILADELPHIA RD
WHITE MARSH MD
21162-1717
US

V. Phone/Fax

Practice location:
  • Phone: 410-544-4600
  • Fax: 410-544-0997
Mailing address:
  • Phone: 410-335-0008
  • Fax: 410-335-3113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberH68311
License Number StateMD

VIII. Authorized Official

Name: JARED EMERSON MALLALIEU
Title or Position: OWNER/DIRECTOR
Credential: D.O.
Phone: 410-544-4600