Provider Demographics
NPI:1851426878
Name:OLD NATIONAL OB- GYN, LLC
Entity Type:Organization
Organization Name:OLD NATIONAL OB- GYN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TYRONE
Authorized Official - Middle Name:C
Authorized Official - Last Name:MALLOY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-991-7552
Mailing Address - Street 1:6210 OLD NATIONAL HWY
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30349-4330
Mailing Address - Country:US
Mailing Address - Phone:770-991-7552
Mailing Address - Fax:
Practice Address - Street 1:6210 OLD NATIONAL HWY
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-4330
Practice Address - Country:US
Practice Address - Phone:770-991-7552
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA621111207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00022741MMedicaid