MEDICARE: NEIL J. MALLIS, M.D. INC

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	207R00000X	Internal Medicine Physician	MD031074E	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2079177	OTHER	PA	HIGHMARK BLUE SHIELD
2	3553245000	OTHER	PA	PERSONAL CHOICE
3	3553245001	OTHER	PA	KEYSTONE IBC

General Provider Information

NPI Number	:	1699912618
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEIL J. MALLIS, M.D. INC

Provider Business Mailing Address
First Line	:	7335 FRANKFORD AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19136-3929
Country	:	US
Telephone Number	:	215-335-1220
Fax Number	:	215-335-2517

Provider Business Practice Location Address
First Line	:	7335 FRANKFORD AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19136-3929
Country	:	US
Telephone Number	:	215-335-1220
Fax Number	:	215-335-2517

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	NEIL J. MALLIS
Credential	:
Telephone Number	:	215-335-1220

Provider Enumeration Date	:	01/13/2009
Last Update Date	:	03/05/2009

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