Basic Information
| Provider Information | |||||||||
| NPI: | 1891766176 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MALIS | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 56 WINTHROP ST | ||||||||
| Address2: | UNIT 1 THE CONCORD CLINIC | ||||||||
| City: | CONCORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017422076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9783692266 | ||||||||
| FaxNumber: | 9783695205 | ||||||||
| Practice Location | |||||||||
| Address1: | 107 COMMERCIAL ST | ||||||||
| Address2: | |||||||||
| City: | MASHPEE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5084777090 | ||||||||
| FaxNumber: | 5084773090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2006 | ||||||||
| LastUpdateDate: | 06/15/2018 | ||||||||
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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 | 207R00000X | 58602 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | 58602 | MA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3024741 | 05 | MA | MEDICAID |