Provider Demographics
NPI:1225174162
Name:MALAS, BRYAN S (MHPE, CO)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:S
Last Name:MALAS
Suffix:
Gender:M
Credentials:MHPE, CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2056 W BRADLEY PL
Mailing Address - Street 2:#2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-4908
Mailing Address - Country:US
Mailing Address - Phone:773-935-6751
Mailing Address - Fax:
Practice Address - Street 1:2300 N CHILDRENS PLZ
Practice Address - Street 2:#46
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-3363
Practice Address - Country:US
Practice Address - Phone:773-327-1061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist