Healthcare Provider Details

I. General information

NPI: 1386136315
Provider Name (Legal Business Name): ALPHA OMEGA MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 06/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36503 US HIGHWAY 19 N
PALM HARBOR FL
34684
US

IV. Provider business mailing address

5750 RUSACK DR
MELBOURNE FL
32940-8016
US

V. Phone/Fax

Practice location:
  • Phone: 201-925-1105
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME131622
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO3900
License Number StateFL

VIII. Authorized Official

Name: DR. RAYMON HANNA
Title or Position: PODIATRIST/FOOT AND ANKLE SURGEON
Credential: DPM
Phone: 201-925-1105