Healthcare Provider Details

I. General information

NPI: 1174099147
Provider Name (Legal Business Name): OMNIVAS NWI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2018
Last Update Date: 10/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8127 MERRILLVILLE RD STE 1
MERRILLVILLE IN
46410-6306
US

IV. Provider business mailing address

8127 MERRILLVILLE RD STE 1
MERRILLVILLE IN
46410-6306
US

V. Phone/Fax

Practice location:
  • Phone: 260-333-1805
  • Fax: 702-991-7258
Mailing address:
  • Phone: 260-333-1805
  • Fax: 702-991-7258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. CHAND HOODBHOY
Title or Position: CREDENTIALER
Credential:
Phone: 702-858-7376