Basic Information
| Provider Information | |||||||||
| NPI: | 1770518367 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALLY | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | ALLEN | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5987 | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486030987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894014245 | ||||||||
| FaxNumber: | 9894014235 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 N CENTER RD STE 400 | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486037920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897539000 | ||||||||
| FaxNumber: | 9897534024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 09/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 5101013484 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.