Healthcare Provider Details

I. General information

NPI: 1093338428
Provider Name (Legal Business Name): SAMUEL O'MELIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2020
Last Update Date: 11/07/2025
Certification Date: 11/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11430 N PORT WASHINGTON RD
MEQUON WI
53092-3414
US

IV. Provider business mailing address

11430 N PORT WASHINGTON RD
MEQUON WI
53092-3414
US

V. Phone/Fax

Practice location:
  • Phone: 262-518-1900
  • Fax: 262-518-1922
Mailing address:
  • Phone: 262-518-1900
  • Fax: 262-518-1922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number175662
License Number StateAK
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number15038-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: