Provider Demographics
NPI:1154301885
Name:MALMSTROM, MARK ALLEN (PT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALLEN
Last Name:MALMSTROM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 CREEK RD
Mailing Address - Street 2:STE 110
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45242
Mailing Address - Country:US
Mailing Address - Phone:513-733-9333
Mailing Address - Fax:513-588-2479
Practice Address - Street 1:4440 GLEN ESTE WITHAMSVILLE RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45245-1318
Practice Address - Country:US
Practice Address - Phone:513-943-3630
Practice Address - Fax:513-753-4308
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT002428225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2631398Medicaid
OHP00323522OtherMEDICARE RAILROAD
OH000000384741OtherANTHEM
OH479351OtherPHCS
OH0225920002Medicare NSC
OHP00323522OtherMEDICARE RAILROAD