Provider Demographics
NPI:1023138237
Name:MALLOW, MICHAEL KEITH (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:KEITH
Last Name:MALLOW
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 1:25 S. 9TH STREET
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4408
Mailing Address - Country:US
Mailing Address - Phone:215-955-1200
Mailing Address - Fax:215-923-6808
Practice Address - Street 1:25 S. 9TH STREET
Practice Address - Street 2:1ST FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4408
Practice Address - Country:US
Practice Address - Phone:215-955-1200
Practice Address - Fax:215-923-6808
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD436445208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1023098190002Medicaid
NJ0272132Medicaid
PAMD436445OtherPA LICENSE
PA152677Medicare PIN