Basic Information
| Provider Information | |||||||||
| NPI: | 1720080906 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALOOF | ||||||||
| FirstName: | ALBERTA | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 840 | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458020840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8775747116 | ||||||||
| FaxNumber: | 4192232726 | ||||||||
| Practice Location | |||||||||
| Address1: | 4605 MACCORKLE AVE SW | ||||||||
| Address2: | |||||||||
| City: | SOUTH CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253091311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047663600 | ||||||||
| FaxNumber: | 3043434626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 06/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 19043 | WV | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0440737 | 05 | OH | MEDICAID | 001718795 | 01 | WV | BLUE CROSS | OTHER | 0122650000 | 05 | WV | MEDICAID |