Provider Demographics
NPI:1861425761
Name:O'MALLEY, EDWARD ANTHONY JR (MPT)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:ANTHONY
Last Name:O'MALLEY
Suffix:JR
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:448 A NORTH WEBER ROAD
Mailing Address - Street 2:
Mailing Address - City:ROMEOVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60446-5354
Mailing Address - Country:US
Mailing Address - Phone:815-293-3740
Mailing Address - Fax:815-293-3742
Practice Address - Street 1:448 A NORTH WEBER ROAD
Practice Address - Street 2:
Practice Address - City:ROMEOVILLE
Practice Address - State:IL
Practice Address - Zip Code:60446-5354
Practice Address - Country:US
Practice Address - Phone:875-293-3740
Practice Address - Fax:815-293-3742
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-008577225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist