Healthcare Provider Details

I. General information

NPI: 1851331441
Provider Name (Legal Business Name): JAMES S MALLERY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 11/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 EXCELSIOR BLVD SUITE 4-820 DIGESTIVE AND ENDOSCOPY CENTER METHODIST HOSPITAL
ST LOUIS PARK MN
55426
US

IV. Provider business mailing address

6500 EXCELSIOR BLVD SUITE 4-820 DIGESTIVE AND ENDOSCOPY CENTER METHODIST HOSPITAL
ST LOUIS PARK MN
55426
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-3240
  • Fax: 952-993-2640
Mailing address:
  • Phone: 952-993-3240
  • Fax: 952-993-2640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number36617
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: