Provider Demographics
NPI:1740427467
Name:MALIRO, TENNYSON M (MD)
Entity Type:Individual
Prefix:
First Name:TENNYSON
Middle Name:M
Last Name:MALIRO
Suffix:
Gender:M
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:PO BOX 7065
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80537-0065
Mailing Address - Country:US
Mailing Address - Phone:301-503-9055
Mailing Address - Fax:
Practice Address - Street 1:500 N MCLEAN BLVD # 103
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-3275
Practice Address - Country:US
Practice Address - Phone:224-227-6178
Practice Address - Fax:224-238-3237
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-16
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2687222085R0202X
PAMD4356682085R0202X
MDD705412085R0202X
IL036.1645312085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology