Provider Demographics
NPI:1184642993
Name:MAYLACK, FALLON H (MD)
Entity Type:Individual
Prefix:
First Name:FALLON
Middle Name:H
Last Name:MAYLACK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:314-884-6320
Mailing Address - Fax:314-884-6321
Practice Address - Street 1:12255 DE PAUL DR
Practice Address - Street 2:STE 845
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2510
Practice Address - Country:US
Practice Address - Phone:314-884-6320
Practice Address - Fax:314-884-6321
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR5E50207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207746702Medicaid
MOA13442Medicare UPIN
MO124510111Medicare PIN