Basic Information
| Provider Information | |||||||||
| NPI: | 1760465165 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALENCH | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 PROFESSIONAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620625672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182887244 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10 PROFESSIONAL PARK DR | ||||||||
| Address2: | |||||||||
| City: | MARYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620625672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182887244 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2005 | ||||||||
| LastUpdateDate: | 06/23/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 03689542 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | 036089542 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03089542 | 05 | IL | MEDICAID | 204900500 | 05 | MO | MEDICAID | 036089542 | 05 | IL | MEDICAID |