Organization
OLD NATIONAL OB- GYN, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. TYRONE C MALLOY M.D. (OWNER)
(770) 991-7552
Entity
Organization
Contact information
Practice address
6210 OLD NATIONAL HWY, COLLEGE PARK, GA 30349-4330
(770) 991-7552
Mailing address
6210 OLD NATIONAL HWY, COLLEGE PARK, GA 30349-4330
(770) 991-7552
Taxonomy
Speciality
Code
Description
License number
State
207VG0400X
Gynecology Physician
Primary
621111
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00022741M
—
GA
Enumeration date
02/22/2007
Last updated
05/03/2010
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