Basic Information
| Provider Information | |||||||||
| NPI: | 1174729131 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'MALLEY | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | BLAIR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2355 HWY 36 W. | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512922000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2355 HWY 36 W | ||||||||
| Address2: | STE. 100 | ||||||||
| City: | ROSEVILLE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512922000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2007 | ||||||||
| LastUpdateDate: | 07/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 4301090572 | MI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 70875 | MN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.