Basic Information
Provider Information | |||||||||
NPI: | 1407230501 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | O' MALLEY | ||||||||
FirstName: | GRAINNE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 781076 | ||||||||
Address2: |   | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482781076 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3175284800 | ||||||||
FaxNumber: | 3178651479 | ||||||||
Practice Location | |||||||||
Address1: | 118 W DREXEL PKWY | ||||||||
Address2: |   | ||||||||
City: | RENSSELAER | ||||||||
State: | IN | ||||||||
PostalCode: | 47978 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2198664300 | ||||||||
FaxNumber: | 2198667591 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/17/2015 | ||||||||
LastUpdateDate: | 03/18/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/18/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01080931A | IN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 125067889 | IL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 300019370 | 05 | IN |   | MEDICAID | 000001199850 | 01 |   | ANTHEM | OTHER |