Provider Demographics
NPI:1003849779
Name:KAILASAM, MALA T (MD)
Entity Type:Individual
Prefix:MS
First Name:MALA
Middle Name:T
Last Name:KAILASAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:333 COTTMAN AVE
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-2434
Mailing Address - Country:US
Mailing Address - Phone:215-728-6900
Mailing Address - Fax:215-214-1425
Practice Address - Street 1:333 COTTMAN AVE
Practice Address - Street 2:FOX CHASE CANCER CENTER
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2434
Practice Address - Country:US
Practice Address - Phone:215-728-6900
Practice Address - Fax:215-214-1425
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA434586208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1022444470001Medicaid
PA140445FH8Medicare PIN