Provider Demographics
NPI:1952400806
Name:OMALLEY FOOT AND ANKLE PA
Entity Type:Organization
Organization Name:OMALLEY FOOT AND ANKLE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENTOWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:OMALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:910-251-9880
Mailing Address - Street 1:1505 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7507
Mailing Address - Country:US
Mailing Address - Phone:910-251-9880
Mailing Address - Fax:910-251-9297
Practice Address - Street 1:1505 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7507
Practice Address - Country:US
Practice Address - Phone:910-251-9880
Practice Address - Fax:910-251-9297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC418213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1284510001OtherMEDICARE DMERC PTAN
NC018H0OtherBCBS-NC
NC790801MMedicaid
NCU65806Medicare UPIN
1284510001Medicare NSC
NC2433365Medicare ID - Type Unspecified