Provider Demographics
NPI:1578862645
Name:WALLY S. MAHAR, M.D. P.L.L.C.
Entity Type:Organization
Organization Name:WALLY S. MAHAR, M.D. P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O CHAIRMAN OF THE BOARD OF DIRE
Authorized Official - Prefix:DR
Authorized Official - First Name:WALLY
Authorized Official - Middle Name:SHERMAN
Authorized Official - Last Name:MAHAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-556-1997
Mailing Address - Street 1:21 MIDLAND ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48203-3727
Mailing Address - Country:US
Mailing Address - Phone:586-556-1997
Mailing Address - Fax:313-731-7025
Practice Address - Street 1:21 MIDLAND ST
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:MI
Practice Address - Zip Code:48203-3727
Practice Address - Country:US
Practice Address - Phone:586-556-1997
Practice Address - Fax:313-731-7025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-15
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301030215207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301030215OtherLICENSE