Provider Demographics
NPI:1164452611
Name:MALONEY, MICHAEL BERNARD (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BERNARD
Last Name:MALONEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9951 ROCK CUT XING
Mailing Address - Street 2:
Mailing Address - City:LOVES PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61111-1999
Mailing Address - Country:US
Mailing Address - Phone:815-639-8500
Mailing Address - Fax:815-639-8501
Practice Address - Street 1:9951 ROCK CUT XING
Practice Address - Street 2:
Practice Address - City:LOVES PARK
Practice Address - State:IL
Practice Address - Zip Code:61111-1999
Practice Address - Country:US
Practice Address - Phone:815-639-8500
Practice Address - Fax:815-639-8501
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036070824207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL553180OtherGRUOP #
IL036070824Medicaid
IL834340OtherMEDICARE GROUP PTAN
IL553180OtherGRUOP #
ILE18581Medicare UPIN
IL553180004Medicare PIN
IL110176464Medicare ID - Type UnspecifiedRR INDIVIDUAL #
IL036070824Medicaid
ILL66624Medicare ID - Type Unspecified
ILCC5050Medicare ID - Type UnspecifiedRR MEDICARE GROUP #