Basic Information
| Provider Information | |||||||||
| NPI: | 1336254218 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALLORY | ||||||||
| FirstName: | HARVEY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | IV | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 95590 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871995590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058189247 | ||||||||
| FaxNumber: | 5052173950 | ||||||||
| Practice Location | |||||||||
| Address1: | 7000 JEFFERSON ST NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053449478 | ||||||||
| FaxNumber: | 5053442783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 07/26/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | MD2006-0166 | NM | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 207LP2900X | MD2006-0166 | NM | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2006-0166 | 01 | NM | LICENSE NUMBER | OTHER |