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General NPI Number Information
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NPI Number | 1851426878
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Entity Type | Organization
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Legal Business Name | OLD NATIONAL OB- GYN, LLC
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Dates
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Enumeration Date | 02/22/2007
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Last Update Date | 05/03/2010
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Provider Practice Location Address
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Address Line | 6210 OLD NATIONAL HWY
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City | COLLEGE PARK
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State | GA
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Zip | 30349-4330
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Country | US
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Telephone | 770-991-7552
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Fax |
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Provider Business Mailing Address
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Address Line | 6210 OLD NATIONAL HWY
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City | COLLEGE PARK
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State | GA
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Zip | 30349-4330
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Country | US
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Telephone | 770-991-7552
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. TYRONE C MALLOY
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Credential | M.D.
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Telephone | 770-991-7552
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207VG0400X
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Taxonomy Name | Gynecology Physician
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License Number | 621111
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License Number State | GA
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