MEDICARE: MARK A OMALLEY DO PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	3364	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	438582	OTHER	AZ	AHCCCS

General Provider Information

NPI Number	:	1538122197
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARK A OMALLEY DO PC

Provider Business Mailing Address
First Line	:	4757 EAST GREENWAY ROAD 107B
Second Line	:	PMB 189
City	:	PHOENIX
State	:	AZ
Zip	:	85032-8510
Country	:	US
Telephone Number	:	602-862-9390
Fax Number	:	602-862-9390

Provider Business Practice Location Address
First Line	:	3420 EAST ANDERSON DRIVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85032
Country	:	US
Telephone Number	:	602-862-9390
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MARK ALAN OMALLEY
Credential	:	DO
Telephone Number	:	602-862-9390

Provider Enumeration Date	:	04/06/2006
Last Update Date	:	11/02/2007

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