Provider Demographics
NPI:1811141740
Name:MALLAN, JOSH
Entity type:Individual
Prefix:
First Name:JOSH
Middle Name:
Last Name:MALLAN
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 1:1444 W GRANVILLE AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-1800
Mailing Address - Country:US
Mailing Address - Phone:773-294-8200
Mailing Address - Fax:
Practice Address - Street 1:1444 W GRANVILLE AVE APT 3
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-1800
Practice Address - Country:US
Practice Address - Phone:773-294-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-05
Last Update Date:2008-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications