Provider Demographics
NPI:1871625509
Name:O'MALLEY, TIFFANY M (MED)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:M
Last Name:O'MALLEY
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:459 W CAMBRIA DR
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60073-3213
Mailing Address - Country:US
Mailing Address - Phone:847-740-0971
Mailing Address - Fax:847-740-0971
Practice Address - Street 1:459 W CAMBRIA DR
Practice Address - Street 2:
Practice Address - City:ROUND LAKE
Practice Address - State:IL
Practice Address - Zip Code:60073-3213
Practice Address - Country:US
Practice Address - Phone:847-740-0971
Practice Address - Fax:847-740-0971
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist