Provider Demographics
NPI:1851331441
Name:MALLERY, JAMES S (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:S
Last Name:MALLERY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:6500 EXCELSIOR BLVD SUITE 4-820
Mailing Address - Street 2:DIGESTIVE AND ENDOSCOPY CENTER METHODIST HOSPITAL
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426
Mailing Address - Country:US
Mailing Address - Phone:952-993-3240
Mailing Address - Fax:952-993-2640
Practice Address - Street 1:6500 EXCELSIOR BLVD SUITE 4-820
Practice Address - Street 2:DIGESTIVE AND ENDOSCOPY CENTER METHODIST HOSPITAL
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426
Practice Address - Country:US
Practice Address - Phone:952-993-3240
Practice Address - Fax:952-993-2640
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2012-11-07
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Provider Licenses
StateLicense IDTaxonomies
MN36617207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN834323300Medicaid
MN110005138Medicare ID - Type Unspecified
G71108Medicare UPIN