Basic Information
| Provider Information | |||||||||
| NPI: | 1003849779 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAILASAM | ||||||||
| FirstName: | MALA | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 COTTMAN AVE | ||||||||
| Address2: | MEDICAL STAFF OFFICE | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191112434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157286900 | ||||||||
| FaxNumber: | 2152141425 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 COTTMAN AVE | ||||||||
| Address2: | FOX CHASE CANCER CENTER | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191112434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157286900 | ||||||||
| FaxNumber: | 2152141425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 03/08/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 434586 | PA | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 434586 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1022444470001 | 05 | PA | MEDICAID |