Basic Information
| Provider Information | |||||||||
| NPI: | 1073587101 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALONE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 400 HOSPITAL DR STE 111 | ||||||||
| Address2: | |||||||||
| City: | CORSICANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751102489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036414895 | ||||||||
| FaxNumber: | 9036414894 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 HOSPITAL DR | ||||||||
| Address2: | STE 201 | ||||||||
| City: | CORSICANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751102489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036414870 | ||||||||
| FaxNumber: | 9036414877 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 09/14/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | L7028 | TX | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 160314402 | 05 | TX | MEDICAID | 160314403 | 05 | TX | MEDICAID | 8W4545 | 01 | TX | BLUE CROSS | OTHER |