Basic Information
| Provider Information | |||||||||
| NPI: | 1881618239 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALNOR | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5329 | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486030329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163646700 | ||||||||
| FaxNumber: | 9894014245 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 JEFFESON SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163646700 | ||||||||
| FaxNumber: | 6163644960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 09/10/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 4301048475 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 1662851100 | 05 | MI | MEDICAID | 300044873 | 01 | MI | RR MEDICAID | OTHER |