Provider Demographics
NPI:1316097207
Name:MALCOMSON, ROBERT F (RN)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:F
Last Name:MALCOMSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 SANDPIPER CT
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3325
Mailing Address - Country:US
Mailing Address - Phone:631-366-4261
Mailing Address - Fax:
Practice Address - Street 1:998 CROOKED HILL RD
Practice Address - Street 2:
Practice Address - City:W BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-1043
Practice Address - Country:US
Practice Address - Phone:631-306-5778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY473687-1163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY473687-1Medicaid