Provider Demographics
NPI:1932264207
Name:GREGORY MALO PSYD & ASSOCIATES IN NEUROPSYCHOLOGY PC
Entity Type:Organization
Organization Name:GREGORY MALO PSYD & ASSOCIATES IN NEUROPSYCHOLOGY PC
Other - Org Name:ARCC NEUROPSYCHOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:WARREN
Authorized Official - Last Name:SUMMERVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-424-8900
Mailing Address - Street 1:477 E BUTTERFIELD RD STE 102
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-4880
Mailing Address - Country:US
Mailing Address - Phone:630-424-8900
Mailing Address - Fax:630-424-9017
Practice Address - Street 1:477 E BUTTERFIELD RD STE 102
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-4880
Practice Address - Country:US
Practice Address - Phone:630-424-8900
Practice Address - Fax:630-424-9017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103G00000X
IL071002647261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL071002647OtherLICENSE #
IL02233000OtherBLUE CROSS BLUE SHEILD
IL585220Medicare ID - Type UnspecifiedGROUP PROVIDER #