Healthcare Provider Details

I. General information

NPI: 1235560475
Provider Name (Legal Business Name): CHRISTOPHER THOMAS MALLOY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2013
Last Update Date: 06/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 N BROAD ST
PHILADELPHIA PA
19102-1121
US

IV. Provider business mailing address

24 S 18TH ST
ALLENTOWN PA
18104-5622
US

V. Phone/Fax

Practice location:
  • Phone: 215-762-7922
  • Fax: 215-762-8656
Mailing address:
  • Phone: 610-628-8372
  • Fax: 610-628-8648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR15663400
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN600018
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: