Provider Demographics
NPI:1578889614
Name:MALLOY, PHILLIP J (PT)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:J
Last Name:MALLOY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 S MORGAN ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-3668
Mailing Address - Country:US
Mailing Address - Phone:312-421-7274
Mailing Address - Fax:312-421-7289
Practice Address - Street 1:24 S MORGAN ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-3668
Practice Address - Country:US
Practice Address - Phone:312-421-7274
Practice Address - Fax:312-421-7289
Is Sole Proprietor?:No
Enumeration Date:2010-04-14
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-016662225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist