Provider Demographics
NPI:1700230075
Name:NEBERGALL, MALLORY (MD)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:NEBERGALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 W. UNIVERSITY AVE. STE 401
Mailing Address - Street 2:IU HEALTH BALL MEMORIAL HOSPITAL
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2525 W. UNIVERSITY AVE. STE 401
Practice Address - Street 2:IU HEALTH BALL MEMORIAL HOSPITAL
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303
Practice Address - Country:US
Practice Address - Phone:765-747-4306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-22
Last Update Date:2022-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMD469326207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL161402094Medicaid