=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497465306
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MALCOLM MAURO PT, DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2022
-----------------------------------------------------
Last Update Date | 10/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7253 S 76TH ST
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53132-9041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-425-9700
-----------------------------------------------------
Fax | 414-425-9701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 625 KENMOOR AVE SE STE 100
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49546-2395
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-356-5000
-----------------------------------------------------
Fax | 616-356-5001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | CP049267T
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------