MEDICARE: MALLICK QAISER ALAM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	034112	CT

General Provider Information

NPI Number	:	1467529271
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALLICK QAISER ALAM MD

Provider Business Mailing Address
First Line	:	77 GRAND AVE
Second Line	:
City	:	NEW HAVEN
State	:	CT
Zip	:	06513-3906
Country	:	US
Telephone Number	:	203-562-8697
Fax Number	:	203-562-1822

Provider Business Practice Location Address
First Line	:	77 GRAND AVE
Second Line	:
City	:	NEW HAVEN
State	:	CT
Zip	:	06513-3906
Country	:	US
Telephone Number	:	203-562-8697
Fax Number	:	203-562-1822

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	07/08/2007

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