Provider Demographics
NPI:1932137312
Name:MALLOY, EDWARD MARTIN II
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:MARTIN
Last Name:MALLOY
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 UPTON WAY
Mailing Address - Street 2:
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-3619
Mailing Address - Country:US
Mailing Address - Phone:856-227-9621
Mailing Address - Fax:856-227-5157
Practice Address - Street 1:603 N BROAD ST
Practice Address - Street 2:SUITE 100
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-1619
Practice Address - Country:US
Practice Address - Phone:856-845-4488
Practice Address - Fax:856-853-5256
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00324600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist