Provider Demographics
NPI:1376546697
Name:O'MALIA, KELLY KIRSTEN (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:KIRSTEN
Last Name:O'MALIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6265 STATE ROUTE 45
Mailing Address - Street 2:PO BOX 280
Mailing Address - City:BRISTOLVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44402-0280
Mailing Address - Country:US
Mailing Address - Phone:330-889-9009
Mailing Address - Fax:330-889-9278
Practice Address - Street 1:6265 STATE ROUTE 45
Practice Address - Street 2:
Practice Address - City:BRISTOLVILLE
Practice Address - State:OH
Practice Address - Zip Code:44402
Practice Address - Country:US
Practice Address - Phone:330-889-9009
Practice Address - Fax:330-889-9278
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35073030207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH835645OtherCIGNA
OHPO0020658OtherRAILROAD MEDICARE
OH000000284981OtherANTHEM BLUE CROSS BLUE SH
OH5300780OtherAETNA
OH2122385Medicaid
OH5300780OtherAETNA
OHOM0879227Medicare ID - Type Unspecified