MEDICARE: MALIK T BANDEALY 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	207RH0003X	Hematology & Oncology Physician	38678	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568453298
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALIK T BANDEALY MD

Provider Business Mailing Address
First Line	:	6811 118TH AVE
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53142-8420
Country	:	US
Telephone Number	:	262-857-5750
Fax Number	:

Provider Business Practice Location Address
First Line	:	6811 118TH AVE
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53142-8420
Country	:	US
Telephone Number	:	262-857-5750
Fax Number	:

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

Provider Enumeration Date	:	11/02/2005
Last Update Date	:	01/11/2024

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Directions to “ MALIK T BANDEALY MD” Practice Location

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