Healthcare Provider Details

I. General information

NPI: 1952852121
Provider Name (Legal Business Name): OMNI FAMILY MEDICAL SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2016
Last Update Date: 10/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7810 W GOOD HOPE RD
MILWAUKEE WI
53223-4518
US

IV. Provider business mailing address

7810 W GOOD HOPE RD
MILWAUKEE WI
53223-4518
US

V. Phone/Fax

Practice location:
  • Phone: 414-586-9255
  • Fax:
Mailing address:
  • Phone: 414-586-9255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number6454820
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number6454820
License Number StateWI

VIII. Authorized Official

Name: MURTIS GRANT-ACQUAH
Title or Position: OFFICE MANAGER
Credential:
Phone: 414-374-9575