MEDICARE: ANDREW CHARLES MALLOY PT

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	225100000X	Physical Therapist	05009281A	IN

General Provider Information

NPI Number	:	1992868103
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREW CHARLES MALLOY PT

Provider Business Mailing Address
First Line	:	6626 E 75TH ST STE 500
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46250-2890
Country	:	US
Telephone Number	:	317-621-7547
Fax Number	:	317-581-2436

Provider Business Practice Location Address
First Line	:	8890 E 116TH ST STE 130
Second Line	:
City	:	FISHERS
State	:	IN
Zip	:	46038-2856
Country	:	US
Telephone Number	:	317-621-6740
Fax Number	:

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

Provider Enumeration Date	:	12/18/2006
Last Update Date	:	02/13/2023

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