Healthcare Provider Details

I. General information

NPI: 1043235377
Provider Name (Legal Business Name): MICHAEL CRAIG MALLEA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3355 RIVERBEND DR STE 200
SPRINGFIELD OR
97477-8800
US

IV. Provider business mailing address

3355 RIVERBEND DR STE 200
SPRINGFIELD OR
97477-8800
US

V. Phone/Fax

Practice location:
  • Phone: 541-868-9247
  • Fax: 541-485-0452
Mailing address:
  • Phone: 541-868-9247
  • Fax: 541-485-0452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberM7108
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberM7108
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberMD20251
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: