Provider Demographics
NPI:1073673562
Name:CORLEY, MALCOLM O (MD)
Entity type:Individual
Prefix:MR
First Name:MALCOLM
Middle Name:O
Last Name:CORLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 WAMSUTTA MILL ROAD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28655-5522
Mailing Address - Country:US
Mailing Address - Phone:828-430-3511
Mailing Address - Fax:336-464-2907
Practice Address - Street 1:125 WAMSUTTA MILL ROAD
Practice Address - Street 2:SUITE D
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-5522
Practice Address - Country:US
Practice Address - Phone:828-430-3511
Practice Address - Fax:336-464-2907
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5520174400000X
174400000X
NC195912085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC400685Medicaid
SC400685Medicaid