Provider Demographics
NPI:1639145436
Name:BHOOSA MALLIAH, MD. PA
Entity Type:Organization
Organization Name:BHOOSA MALLIAH, MD. PA
Other - Org Name:BHOOSAMALLIAH,MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BHOOSA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLIAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-840-8688
Mailing Address - Street 1:222 JACK MARTIN BLVD
Mailing Address - Street 2:SUITE. E,
Mailing Address - City:BRICKTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-7772
Mailing Address - Country:US
Mailing Address - Phone:732-840-8688
Mailing Address - Fax:732-840-8480
Practice Address - Street 1:222 JACK MARTIN BLVD
Practice Address - Street 2:SUITE. E,
Practice Address - City:BRICKTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08724-7772
Practice Address - Country:US
Practice Address - Phone:732-840-8688
Practice Address - Fax:732-840-8480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-23
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJD06502Medicare UPIN
NJ450719Medicare PIN