Healthcare Provider Details

I. General information

NPI: 1649498742
Provider Name (Legal Business Name): MARY B. O'MALLEY M.D., PHD.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/28/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SMMC, DEPT OF PSYCHIATRY 25 JUNE ST
SANFORD ME
04073
US

IV. Provider business mailing address

434B STOCKBRIDGE RD LOWR LEVEL
GREAT BARRINGTON MA
01230-1295
US

V. Phone/Fax

Practice location:
  • Phone: 207-324-4310
  • Fax:
Mailing address:
  • Phone: 203-556-4846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number242178
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number242178
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: