1164810495 NPI number — CLARA O'MALLEY C- PA

Table of content: CLARA O'MALLEY C- PA (NPI 1164810495)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164810495 NPI number — CLARA O'MALLEY C- PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
O'MALLEY
Provider First Name:
CLARA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
C- PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILSON
Provider Other First Name:
CLARA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
C-PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1164810495
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/16/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5783 WOOSTER PIKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MEDINA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44256-8816
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-725-0569
Provider Business Mailing Address Fax Number:
330-662-0258

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5783 WOOSTER PIKE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDINA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44256-8816
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-725-0569
Provider Business Practice Location Address Fax Number:
330-662-0258
Provider Enumeration Date:
01/09/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3025372 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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