Healthcare Provider Details

I. General information

NPI: 1033451455
Provider Name (Legal Business Name): MALLORY HANNAH SALENTINE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MALLORY HANNAH COHEN M.D.

II. Dates (important events)

Enumeration Date: 03/24/2013
Last Update Date: 09/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8375 S HOWELL AVE
OAK CREEK WI
53154-8344
US

IV. Provider business mailing address

9000 W WISCONSIN AVE MS 958
MILWAUKEE WI
53226-4874
US

V. Phone/Fax

Practice location:
  • Phone: 414-764-5726
  • Fax: 414-764-6954
Mailing address:
  • Phone: 414-266-7615
  • Fax: 414-266-6238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number62745-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: