MEDICARE: MALLORY MICKUS

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	2255A2300X	Athletic Trainer	36001700A	IN

General Provider Information

NPI Number	:	1659785137
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALLORY MICKUS

Provider Business Mailing Address
First Line	:	2200 W SUDBURY DR
Second Line	:	E2
City	:	BLOOMINGTON
State	:	IN
Zip	:	47403-3736
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 W SUDBURY DR
Second Line	:	E2
City	:	BLOOMINGTON
State	:	IN
Zip	:	47403-3736
Country	:	US
Telephone Number	:	219-921-4028
Fax Number	:

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

Provider Enumeration Date	:	06/12/2014
Last Update Date	:	06/12/2014

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Directions to “ MALLORY MICKUS ” Practice Location

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