Provider Demographics
NPI:1255366688
Name:MACAULAY, MALCOLM R
Entity type:Individual
Prefix:
First Name:MALCOLM
Middle Name:R
Last Name:MACAULAY
Suffix:
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 1:4855 W ARROWHEAD RD
Mailing Address - Street 2:
Mailing Address - City:HERMANTOWN
Mailing Address - State:MN
Mailing Address - Zip Code:55811-3936
Mailing Address - Country:US
Mailing Address - Phone:218-786-3540
Mailing Address - Fax:218-722-8160
Practice Address - Street 1:4855 W ARROWHEAD RD
Practice Address - Street 2:
Practice Address - City:HERMANTOWN
Practice Address - State:MN
Practice Address - Zip Code:55811-3936
Practice Address - Country:US
Practice Address - Phone:218-786-3540
Practice Address - Fax:218-722-8160
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4019225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40257200Medicaid