=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770901670
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN O'MALLEY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2014
-----------------------------------------------------
Last Update Date | 09/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3800 RESERVOIR RD NW DEPT. OF ORTHOPAEDIC SURGERY
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20007-2113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-444-8766
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4654 CHARLESTON TER NW
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20007-1900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-318-2281
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | MD048567
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------