Provider Demographics
NPI:1528265816
Name:MALLETT, ERIC MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:MICHAEL
Last Name:MALLETT
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 1:35472 FREDERICKSBURG RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-2530
Mailing Address - Country:US
Mailing Address - Phone:248-994-0106
Mailing Address - Fax:248-994-0106
Practice Address - Street 1:486 RANDALL RD UNIT B
Practice Address - Street 2:
Practice Address - City:SOUTH ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60177-3354
Practice Address - Country:US
Practice Address - Phone:224-783-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.125880207P00000X, 207Q00000X
IN01094571A207Q00000X
MI4301090660207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700H231390OtherBCBS GROUP NUMBER
IN300095036Medicaid