Healthcare Provider Details

I. General information

NPI: 1700037009
Provider Name (Legal Business Name): CYRUS J. MALI, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2008
Last Update Date: 10/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 MACCORKLE AVE SE SUITE 500
CHARLESTON WV
25304-1223
US

IV. Provider business mailing address

3100 MACCORKLE AVE SE SUITE 500
CHARLESTON WV
25304-1223
US

V. Phone/Fax

Practice location:
  • Phone: 304-342-0703
  • Fax: 304-342-2890
Mailing address:
  • Phone: 304-342-0703
  • Fax: 304-342-2890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number10754
License Number StateWV

VIII. Authorized Official

Name: DR. CYRUS J. MALI
Title or Position: PRESIDENT
Credential:
Phone: 304-342-2890