Individual
DR. BRENDA SUSAN MALLORY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
601 W 2ND ST, BLOOMINGTON, IN 47403-2317
(812) 353-6821
Mailing address
PO BOX 858, MC A410, HERSHEY, PA 17033-0858
(800) 243-1455
Taxonomy
Speciality
Code
Description
License number
State
208100000X
Physical Medicine & Rehabilitation Physician
Primary
01084397A
IN
208100000X
Physical Medicine & Rehabilitation Physician
191473-1
NY
208100000X
Physical Medicine & Rehabilitation Physician
MD440148
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
01417674
—
NY
05
—
1024982060001
—
PA
01
—
191473-1
NY STATE LICENSE
NY
Enumeration date
06/01/2005
Last updated
09/01/2020
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