Provider Demographics
NPI:1194814996
Name:MALIK, GERIANNE LYNN (PAC)
Entity Type:Individual
Prefix:
First Name:GERIANNE
Middle Name:LYNN
Last Name:MALIK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:GERIANNE
Other - Middle Name:LYNN
Other - Last Name:MELDRUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:18325 10 MILE ROAD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4990
Mailing Address - Country:US
Mailing Address - Phone:586-775-4594
Mailing Address - Fax:586-775-4506
Practice Address - Street 1:18325 10 MILE ROAD
Practice Address - Street 2:SUITE 400
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4990
Practice Address - Country:US
Practice Address - Phone:586-775-4594
Practice Address - Fax:586-775-4506
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002957363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI065 501 3610OtherBCBS
MIOH-26467018Medicare PIN