Provider Demographics
NPI:1053542985
Name:JARED MALLALIEU, PA
Entity type:Organization
Organization Name:JARED MALLALIEU, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:EMERSON
Authorized Official - Last Name:MALLALIEU
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:410-544-4600
Mailing Address - Street 1:10845 PHILADELPHIA RD
Mailing Address - Street 2:
Mailing Address - City:WHITE MARSH
Mailing Address - State:MD
Mailing Address - Zip Code:21162-1717
Mailing Address - Country:US
Mailing Address - Phone:410-335-0008
Mailing Address - Fax:410-335-3113
Practice Address - Street 1:484 RITCHIE HWY
Practice Address - Street 2:SUITE A
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-2961
Practice Address - Country:US
Practice Address - Phone:410-544-4600
Practice Address - Fax:410-544-0997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-27
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH68311208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD242301OtherJHHC
MD174406OtherMEDICARE
MDD92MJEOtherCAREFIRST
DCU993OtherCAREFIRST