Provider Demographics
NPI:1770802795
Name:BASU MALLICK, ATRAYEE (MD)
Entity type:Individual
Prefix:
First Name:ATRAYEE
Middle Name:
Last Name:BASU MALLICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 CHESTNUT ST
Mailing Address - Street 2:14TH FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-4404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1015 CHESTNUT ST
Practice Address - Street 2:SUITE 1321
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4316
Practice Address - Country:US
Practice Address - Phone:215-923-5676
Practice Address - Fax:215-923-7390
Is Sole Proprietor?:No
Enumeration Date:2010-06-01
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD440064207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0233242Medicaid
PA102474760Medicaid
NJ0233242Medicaid