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NPI Code Detail

MEDICARE: MALLORY BROOKE O'NIEL

MEDICARE: MALLORY BROOKE O'NIEL
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
1390200000XStudent in an Organized Health Care Education/Training Program
2207YP0228XPediatric Otolaryngology Physician4301112964MI

General Provider Information

NPI Number : 1528357506
Entity Type Code : Individual
Provider Name (Legal Business Name) : MALLORY BROOKE O'NIEL
Provider Business Mailing Address
First Line : 3901 BEAUBIEN ST STE 2102
Second Line :
City : DETROIT
State : MI
Zip : 48201-2119
Country : US
Telephone Number : 313-745-9048
Fax Number : 313-993-3879
Provider Business Practice Location Address
First Line : 3901 BEAUBIEN ST STE 2102
Second Line :
City : DETROIT
State : MI
Zip : 48201-2119
Country : US
Telephone Number : 313-745-9048
Fax Number : 313-993-3879
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/30/2011
Last Update Date : 07/21/2022

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Directions to “ MALLORY BROOKE O'NIEL ” Practice Location

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