Basic Information
| Provider Information | |||||||||
| NPI: | 1790813863 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MALLICO | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 YADKIN ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | ALBEMARLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280013447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049837320 | ||||||||
| FaxNumber: | 7049836153 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 YADKIN ST | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | ALBEMARLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280013449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049820161 | ||||||||
| FaxNumber: | 7049822361 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2007 | ||||||||
| LastUpdateDate: | 10/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 116331 | NC | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1511E | 01 | NC | BCBS | OTHER | 5910179 | 05 | NC | MEDICAID |