Provider Demographics
NPI:1760465165
Name:MALENCH, PETER B (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:B
Last Name:MALENCH
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 1:10 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-5672
Mailing Address - Country:US
Mailing Address - Phone:618-288-7244
Mailing Address - Fax:
Practice Address - Street 1:10 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5672
Practice Address - Country:US
Practice Address - Phone:618-288-7244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03689542207Q00000X
IL036089542207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03089542Medicaid
MO204900500Medicaid
IL036089542Medicaid
MO204900500Medicaid
ILL75321Medicare PIN
ILF95463Medicare UPIN