Basic Information
Provider Information | |||||||||
NPI: | 1477552750 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | A. TARIQ MALIK, MD, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 340 MAIN ST | ||||||||
Address2: | STE. 670 | ||||||||
City: | WORCESTER | ||||||||
State: | MA | ||||||||
PostalCode: | 016081604 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5087543566 | ||||||||
FaxNumber: | 5087988012 | ||||||||
Practice Location | |||||||||
Address1: | 250 GREEN ST | ||||||||
Address2: | STE 212 | ||||||||
City: | GARDNER | ||||||||
State: | MA | ||||||||
PostalCode: | 014401396 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9786327530 | ||||||||
FaxNumber: | 9786320516 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2005 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MALIK | ||||||||
AuthorizedOfficialFirstName: | A. | ||||||||
AuthorizedOfficialMiddleName: | TARIQ | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9786327530 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X |   | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 9707093 | 05 | MA |   | MEDICAID |