Healthcare Provider Details

I. General information

NPI: 1003802414
Provider Name (Legal Business Name): JEFFERSON ASSOC IN INTERNAL MED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 07/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 COAL VALLEY RD SUITE 405
CLAIRTON PA
15025-3730
US

IV. Provider business mailing address

575 COAL VALLEY RD SUITE 405
CLAIRTON PA
15025-3730
US

V. Phone/Fax

Practice location:
  • Phone: 412-466-6161
  • Fax: 412-466-0614
Mailing address:
  • Phone: 412-466-6161
  • Fax: 412-466-0614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD016592E
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberMD016592E
License Number StatePA

VIII. Authorized Official

Name: MICHAEL I MALLINGER
Title or Position: MD OWNER OF CORP
Credential: MD
Phone: 412-466-6161