Basic Information
| Provider Information | |||||||||
| NPI: | 1063522829 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOLLEY | ||||||||
| FirstName: | MALCOLM | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22250 BULVERDE RD STE 120 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782613082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104018185 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 22250 BULVERDE RD STE 120 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782613082 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104018185 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 11/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | ME100702 | FL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | Q0368 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03829 | 01 | FL | BLUE SHIELD | OTHER | 000647800 | 05 | FL | MEDICAID |