Basic Information
Provider Information | |||||||||
NPI: | 1427138528 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MALCOLM | ||||||||
FirstName: | GREGORY | ||||||||
MiddleName: | R | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3387 | ||||||||
Address2: |   | ||||||||
City: | FREDERICK | ||||||||
State: | MD | ||||||||
PostalCode: | 217053387 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8882761910 | ||||||||
FaxNumber: | 8037081370 | ||||||||
Practice Location | |||||||||
Address1: | 240 STONERIDGE DR | ||||||||
Address2: | SUITE 304 | ||||||||
City: | COLUMBIA | ||||||||
State: | SC | ||||||||
PostalCode: | 292108013 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8037088126 | ||||||||
FaxNumber: | 8037081370 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/16/2006 | ||||||||
LastUpdateDate: | 09/03/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 12464 | SC | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207LC0200X | 12464 | SC | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 207LP2900X | 12464 | SC | N |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | 2001038 | 01 | SC | CCP | OTHER | 124644 | 01 | SC | SELECT HEALTH | OTHER | 77844 | 01 | SC | MEDCOST | OTHER | 050028871 | 01 | SC | RR MEDICARE | OTHER | 4130018 | 01 | SC | AETNA | OTHER | 124644 | 05 | SC |   | MEDICAID |