Provider Demographics
NPI:1407902141
Name:MALIS, RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:MALIS
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 1:750 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-7612
Mailing Address - Country:US
Mailing Address - Phone:847-742-1040
Mailing Address - Fax:
Practice Address - Street 1:750 S STATE ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-7612
Practice Address - Country:US
Practice Address - Phone:847-742-1040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-104239207R00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine