Provider Demographics
NPI:1083605612
Name:OMALLEY, TERRENCE ADAMS (MD)
Entity Type:Individual
Prefix:
First Name:TERRENCE
Middle Name:ADAMS
Last Name:OMALLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-1402
Mailing Address - Country:US
Mailing Address - Phone:617-724-4838
Mailing Address - Fax:617-726-9754
Practice Address - Street 1:70 FULTON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02109-1402
Practice Address - Country:US
Practice Address - Phone:617-724-4838
Practice Address - Fax:617-726-9754
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA36969207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM08833OtherBCBS MA
MA036969OtherTUFTS HEALTH PLAN
MA2045214Medicaid
MAM08833Medicare PIN
MAM0883302Medicare PIN
MA2045214Medicaid