=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699912618
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEIL J. MALLIS, M.D. INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2009
-----------------------------------------------------
Last Update Date | 03/05/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7335 FRANKFORD AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19136-3929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-335-1220
-----------------------------------------------------
Fax | 215-335-2517
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7335 FRANKFORD AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19136-3929
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-335-1220
-----------------------------------------------------
Fax | 215-335-2517
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | NEIL J. MALLIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 215-335-1220
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | MD031074E
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------