Basic Information
| Provider Information | |||||||||
| NPI: | 1629040704 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THALER | ||||||||
| FirstName: | MALCOLM | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1790 BROADWAY | ||||||||
| Address2: | SUITE 1802 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100191412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125300624 | ||||||||
| FaxNumber: | 2128674353 | ||||||||
| Practice Location | |||||||||
| Address1: | 1790 BROADWAY | ||||||||
| Address2: | SUITE 1802 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100191412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2125300624 | ||||||||
| FaxNumber: | 2128674353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 04/17/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD030819E | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 263892 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001714840 | 05 | PA | MEDICAID | 232359401 | 01 | PA | MAIN LINE HEALTHCARE | OTHER |