Provider Demographics
NPI:1104125541
Name:ATHANASIOS MALLIOS, M.D., P.C.
Entity type:Organization
Organization Name:ATHANASIOS MALLIOS, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ATHANASIOS
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLIOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-787-0091
Mailing Address - Street 1:15 W 72ND ST
Mailing Address - Street 2:SUITE 1T
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-3402
Mailing Address - Country:US
Mailing Address - Phone:212-787-0091
Mailing Address - Fax:212-721-1636
Practice Address - Street 1:15 W 72ND ST
Practice Address - Street 2:SUITE 1T
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-3402
Practice Address - Country:US
Practice Address - Phone:212-787-0091
Practice Address - Fax:212-721-1636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-24
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY120555207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00305037Medicaid
NY00305037Medicaid
NY343641Medicare PIN