Provider Demographics
NPI:1265469167
Name:O'MALLEY, BERT W JR (MD)
Entity Type:Individual
Prefix:
First Name:BERT
Middle Name:W
Last Name:O'MALLEY
Suffix:JR
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 1:3400 SPRUCE ST
Mailing Address - Street 2:5 WHITE BUILDING
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4206
Mailing Address - Country:US
Mailing Address - Phone:215-662-2777
Mailing Address - Fax:215-662-4613
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:5 SILVERSTEIN BLDG
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-662-2777
Practice Address - Fax:215-662-4613
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2012-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD052827L207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014680400004Medicaid
PA191244Medicare PIN
F86921Medicare UPIN