Provider Demographics
NPI:1508973645
Name:MALISH, RICHARD GLADE (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:GLADE
Last Name:MALISH
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 1:301 ANDREWS AVE
Mailing Address - Street 2:LYSTER ARMY HEALTH CLINIC
Mailing Address - City:FORT RUCKER
Mailing Address - State:AL
Mailing Address - Zip Code:36362-5333
Mailing Address - Country:US
Mailing Address - Phone:334-255-6917
Mailing Address - Fax:
Practice Address - Street 1:301 ANDREWS AVE
Practice Address - Street 2:LYSTER ARMY HEALTH CLINIC
Practice Address - City:FORT RUCKER
Practice Address - State:AL
Practice Address - Zip Code:36362-5333
Practice Address - Country:US
Practice Address - Phone:334-255-6917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN29642207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine