Provider Demographics
NPI:1831283936
Name:MALISH, HAVEN R (MD)
Entity Type:Individual
Prefix:
First Name:HAVEN
Middle Name:R
Last Name:MALISH
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 1:222 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4436
Mailing Address - Country:US
Mailing Address - Phone:701-323-6000
Mailing Address - Fax:
Practice Address - Street 1:222 N 7TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4436
Practice Address - Country:US
Practice Address - Phone:701-323-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND15016207RS0012X
WY12111A207RP1001X, 207RS0012X
WYTL5628207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY152139000Medicaid
MNP00937198OtherRAILROAD MEDICARE
MNENROLLEDMedicaid
MN290000672Medicare PIN