Individual
FALLON H MAYLACK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
12255 DE PAUL DR, STE 845, BRIDGETON, MO 63044-2510
(314) 884-6320
(314) 884-6321
Mailing address
PO BOX 23340, SAINT LOUIS, MO 63156-3340
(314) 884-6320
(314) 884-6321
Taxonomy
Speciality
Code
Description
License number
State
207X00000X
Orthopaedic Surgery Physician
Primary
R5E50
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
207746702
—
MO
Enumeration date
07/18/2006
Last updated
02/13/2017
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