Basic Information
| Provider Information | |||||||||
| NPI: | 1093732091 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALMSTROM | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 255 ENTERPRISE BLVD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296156300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644540888 | ||||||||
| FaxNumber: | 8644541130 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 GROVE RD | ||||||||
| Address2: | GMH ER ADMINISTRATION | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296055611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644556372 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 207PP0204X | 21139 | SC | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 211390 | 05 | SC | MEDICAID | 57-6007863 | 01 | SC | BCBS | OTHER | 57-6007863 | 01 | SC | BLUE CHOICE | OTHER | 57-6007863 | 01 | SC | TRICARE | OTHER | BM5778177 | 01 | SC | FEDERAL DEA | OTHER | 167193 | 01 | SC | UNISON | OTHER | 930081471 | 01 | SC | MEDICARE RAILROAD | OTHER | 20-21139 | 01 | SC | SCCS | OTHER | 20004419 | 01 | SC | SELECT HEALTH | OTHER |