Healthcare Provider Details

I. General information

NPI: 1871724500
Provider Name (Legal Business Name): OMNIVERSE PLASTIKOS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2009
Last Update Date: 12/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 PROFESSIONAL PKWY SUITE C
RIDGELAND MS
39157-4190
US

IV. Provider business mailing address

1888 MAIN ST SUITE C, #272
MADISON MS
39110-6337
US

V. Phone/Fax

Practice location:
  • Phone: 601-824-1492
  • Fax:
Mailing address:
  • Phone: 601-824-1492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number20023
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number20023
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number20023
License Number StateMS

VIII. Authorized Official

Name: DR. ARNO RENE SCHLEICH
Title or Position: PRESIDENT
Credential: MD
Phone: 601-824-1492