Basic Information
| Provider Information | |||||||||
| NPI: | 1093789034 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALLICK | ||||||||
| FirstName: | MEHER | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 840132 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641840132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148433449 | ||||||||
| FaxNumber: | 3148438762 | ||||||||
| Practice Location | |||||||||
| Address1: | 10004 KENNERLY RD | ||||||||
| Address2: | STE 315A | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148433449 | ||||||||
| FaxNumber: | 3148438762 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 02/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 2001009904 | MO | N | Other Service Providers | Specialist | 207RN0300X | 2001009904 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 390007770 | 01 | RAILROAD MEDICARE | OTHER | 6317901 | 05 | IL | MEDICAID | 000013440 | 01 | MEDICARE PTAN | OTHER |