Provider Demographics
NPI:1851671622
Name:MALY, MICHELLE RAE (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:RAE
Last Name:MALY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 N DEARBORN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-4618
Mailing Address - Country:US
Mailing Address - Phone:312-694-2127
Mailing Address - Fax:312-694-2129
Practice Address - Street 1:635 N DEARBORN ST STE 100
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-4618
Practice Address - Country:US
Practice Address - Phone:312-694-2127
Practice Address - Fax:312-694-2129
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-24
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT050762207P00000X
390200000X
IL036141505207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program