Provider Demographics
NPI:1407112501
Name:MAHALKO, ERICH D (CFA)
Entity Type:Individual
Prefix:MR
First Name:ERICH
Middle Name:D
Last Name:MAHALKO
Suffix:
Gender:M
Credentials:CFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 N IL ROUTE 31
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60012-3711
Mailing Address - Country:US
Mailing Address - Phone:815-356-5200
Mailing Address - Fax:815-356-5262
Practice Address - Street 1:420 N IL ROUTE 31
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012
Practice Address - Country:US
Practice Address - Phone:815-356-5200
Practice Address - Fax:815-356-5262
Is Sole Proprietor?:No
Enumeration Date:2012-04-03
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238.000417246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL238.000417OtherREGISTERED SURGICAL ASSISTANT LICENSE
117716OtherNATIONAL CERTIFICATION AS A SURGICAL TECHNOLOGIST/FIRST ASSISTANT