Basic Information
| Provider Information | |||||||||
| NPI: | 1184685380 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | O'MALLEY | ||||||||
| FirstName: | BARBARA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1420 STEPHENSON HWY | ||||||||
| Address2: | SUITE 400-CREDENTIALING | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480831189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485815974 | ||||||||
| FaxNumber: | 2485815640 | ||||||||
| Practice Location | |||||||||
| Address1: | 3990 JOHN R ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137458555 | ||||||||
| FaxNumber: | 3137459299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 11/05/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZB0001X | 4301059705 | MI | Y | Allopathic & Osteopathic Physicians | Pathology | Blood Banking & Transfusion Medicine | 207ZP0105X | 4301059705 | MI | N | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4334424 | 05 | MI | MEDICAID | 220F361370 | 01 | MI | BCBSM | OTHER |