Provider Demographics
NPI:1487628962
Name:TYSKO, ERIN O'MALLEY (MD)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:O'MALLEY
Last Name:TYSKO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:
Other - Last Name:O'MALLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7114 RIDGE AVENUE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-3250
Mailing Address - Country:US
Mailing Address - Phone:484-476-1000
Mailing Address - Fax:484-476-9000
Practice Address - Street 1:7114 RIDGE AVENUE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128-3250
Practice Address - Country:US
Practice Address - Phone:484-476-1000
Practice Address - Fax:484-476-9000
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD060625L207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA23-2359401OtherMLHC TIN
PA23-2359401OtherMLHC TIN
PA001745560Medicaid
PA024306HK1Medicare PIN