Provider Demographics
NPI:1215391628
Name:O'MALLEY, THOMAS JOHN
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:JOHN
Last Name:O'MALLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 WALNUT ST
Mailing Address - Street 2:SUITE 620
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1015 WALNUT ST
Practice Address - Street 2:SUITE 620
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5005
Practice Address - Country:US
Practice Address - Phone:215-955-6864
Practice Address - Fax:215-955-2878
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMT211212208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program