Provider Demographics
NPI:1083946792
Name:IMTIAZ A. MALLICK PHYSICIAN P.C
Entity Type:Organization
Organization Name:IMTIAZ A. MALLICK PHYSICIAN P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:IMTIAZ
Authorized Official - Middle Name:A
Authorized Official - Last Name:MALLICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-896-2204
Mailing Address - Street 1:798 ROUTE 9
Mailing Address - Street 2:
Mailing Address - City:FISHKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12524-1393
Mailing Address - Country:US
Mailing Address - Phone:845-896-2204
Mailing Address - Fax:845-896-5173
Practice Address - Street 1:798 ROUTE 9
Practice Address - Street 2:
Practice Address - City:FISHKILL
Practice Address - State:NY
Practice Address - Zip Code:12524-1393
Practice Address - Country:US
Practice Address - Phone:845-896-2204
Practice Address - Fax:845-896-5173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-04
Last Update Date:2022-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196451207R00000X
261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01485712Medicaid
NY=========OtherTAX ID
NY93H111Medicare PIN
NYF87014Medicare UPIN