Provider Demographics
NPI:1104889062
Name:O'MALLEY, EILEEN M (PA-C)
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:M
Last Name:O'MALLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:EILEEN
Other - Middle Name:M
Other - Last Name:OMALLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:24723 DETROIT RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-2526
Mailing Address - Country:US
Mailing Address - Phone:440-617-7027
Mailing Address - Fax:440-892-9083
Practice Address - Street 1:24723 DETROIT RD
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-2526
Practice Address - Country:US
Practice Address - Phone:440-617-7027
Practice Address - Fax:440-892-9083
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50000660363AS0400X
OH50-000660363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000325952OtherANTHEM
OH000000325952OtherANTHEM
OHP91985Medicare UPIN