Healthcare Provider Details

I. General information

NPI: 1811083868
Provider Name (Legal Business Name): OMNIMED LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 04/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9720 S TRYON ST
CHARLOTTE NC
28273-6578
US

IV. Provider business mailing address

9720 S TRYON ST
CHARLOTTE NC
28273-6578
US

V. Phone/Fax

Practice location:
  • Phone: 704-588-7362
  • Fax: 704-588-9127
Mailing address:
  • Phone: 704-588-7362
  • Fax: 704-588-9127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KRISTA BURNS
Title or Position: MARKETING DIRECTOR
Credential:
Phone: 803-329-3136