Provider Demographics
NPI:1629040704
Name:THALER, MALCOLM S (MD)
Entity Type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:S
Last Name:THALER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1790 BROADWAY
Mailing Address - Street 2:SUITE 1802
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-1412
Mailing Address - Country:US
Mailing Address - Phone:212-530-0624
Mailing Address - Fax:212-867-4353
Practice Address - Street 1:1790 BROADWAY
Practice Address - Street 2:SUITE 1802
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1412
Practice Address - Country:US
Practice Address - Phone:212-530-0624
Practice Address - Fax:212-867-4353
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2012-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD030819E207R00000X
NY263892207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001714840Medicaid
PA232359401OtherMAIN LINE HEALTHCARE
B40861Medicare UPIN
PA184507HK1Medicare PIN