Healthcare Provider Details

I. General information

NPI: 1386203040
Provider Name (Legal Business Name): MADELYN ELIZABETH O'MALLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2019
Last Update Date: 04/04/2023
Certification Date: 04/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3132 OLD JACKSONVILLE RD STE 200
SPRINGFIELD IL
62704-7401
US

IV. Provider business mailing address

PO BOX 3428
SPRINGFIELD IL
62708-3428
US

V. Phone/Fax

Practice location:
  • Phone: 217-862-0800
  • Fax:
Mailing address:
  • Phone: 217-862-0800
  • Fax: 217-862-0202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125074562
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: