Healthcare Provider Details

I. General information

NPI: 1659845659
Provider Name (Legal Business Name): OMNI MEDICAL CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2019
Last Update Date: 05/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 WAYZATA BLVD E STE 200
WAYZATA MN
55391-2513
US

IV. Provider business mailing address

935 WAYZATA BLVD E STE 200
WAYZATA MN
55391-2513
US

V. Phone/Fax

Practice location:
  • Phone: 763-559-4500
  • Fax: 763-559-1733
Mailing address:
  • Phone: 763-559-4500
  • Fax: 763-559-1733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: BRYAN NICHOLAS ROLFES
Title or Position: PHYSICIAN
Credential: MD
Phone: 763-559-4500