Provider Demographics
NPI:1952374324
Name:MALANTIC-LIN, ANN VALERIE (MD)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:VALERIE
Last Name:MALANTIC-LIN
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 1:106 S CLAUDE A LORD BLVD
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-3637
Mailing Address - Country:US
Mailing Address - Phone:570-622-4209
Mailing Address - Fax:570-622-1386
Practice Address - Street 1:106 S CLAUDE A LORD BLVD
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3637
Practice Address - Country:US
Practice Address - Phone:570-622-4209
Practice Address - Fax:570-622-1386
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD070535L208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0473231OtherUS HEALTHCARE
PA62096OtherGEISINGER HEALTH PLAN
PA0018255540001Medicaid
PA50047338OtherKEYSTONE SPECIALIST
PA50047341OtherCAPITAL BLUE CROSS
PA0000501263OtherBLUE SHIELD
PA50047341OtherKEYSTONE
PA110215361OtherRAILROAD MEDICARE PBA
PA50047341OtherCAPITAL BLUE CROSS
H29874Medicare UPIN