Provider Demographics
NPI:1295989002
Name:E. A. MALACAMAN M. D. LLC
Entity type:Organization
Organization Name:E. A. MALACAMAN M. D. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EDGARDO
Authorized Official - Middle Name:ALTURA
Authorized Official - Last Name:MALACAMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-493-9903
Mailing Address - Street 1:3120 PARKWAY ST NW STE C
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708
Mailing Address - Country:US
Mailing Address - Phone:330-493-9903
Mailing Address - Fax:330-493-9956
Practice Address - Street 1:3120 PARKWAY ST NW STE C
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708
Practice Address - Country:US
Practice Address - Phone:330-493-9903
Practice Address - Fax:330-493-9956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-06
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35034195208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0209429Medicaid