Provider Demographics
NPI:1770518367
Name:MALLY, GARY ALLEN (DO)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:ALLEN
Last Name:MALLY
Suffix:
Gender:M
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:PO BOX 5987
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-0987
Mailing Address - Country:US
Mailing Address - Phone:989-401-4245
Mailing Address - Fax:989-401-4235
Practice Address - Street 1:3400 N CENTER RD STE 400
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-7920
Practice Address - Country:US
Practice Address - Phone:989-753-9000
Practice Address - Fax:989-753-4024
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010134842085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3054613095OtherBCBS PIN #
MI4864538Medicaid
MIP00294905OtherRR MEDICARE #
MI4864538Medicaid
F46000027Medicare PIN
H82314Medicare UPIN
F16002023Medicare PIN