Healthcare Provider Details

I. General information

NPI: 1255366688
Provider Name (Legal Business Name): MALCOLM R MACAULAY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4855 W ARROWHEAD RD
HERMANTOWN MN
55811-3936
US

IV. Provider business mailing address

4855 W ARROWHEAD RD
HERMANTOWN MN
55811-3936
US

V. Phone/Fax

Practice location:
  • Phone: 218-786-3540
  • Fax: 218-722-8160
Mailing address:
  • Phone: 218-786-3540
  • Fax: 218-722-8160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4019
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: