MEDICARE: OMNIMED LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	207P00000X	Emergency Medicine Physician
2	207R00000X	Internal Medicine Physician
3	332B00000X	Durable Medical Equipment & Medical Supplies
4	363L00000X	Nurse Practitioner
5	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DE3289	OTHER	SC	MEDIACID SC - DME
2	4448680	OTHER		AETNA
3	0120I	OTHER	NC	BLUE CROSS BLUE SHIELD NC
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588623433
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMNIMED LLC

Provider Business Mailing Address
First Line	:	2450 INDIA HOOK RD
Second Line	:
City	:	ROCK HILL
State	:	SC
Zip	:	29732-3270
Country	:	US
Telephone Number	:	803-366-7443
Fax Number	:	803-329-1118

Provider Business Practice Location Address
First Line	:	2450 INDIA HOOK RD
Second Line	:
City	:	ROCK HILL
State	:	SC
Zip	:	29732-3270
Country	:	US
Telephone Number	:	803-366-7443
Fax Number	:	803-329-1118

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	JENNIFER RANDEL
Credential	:
Telephone Number	:	803-366-7443

Provider Enumeration Date	:	03/20/2006
Last Update Date	:	03/08/2021

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Directions to “OMNIMED LLC ” Practice Location

Language	Start Address	Practice Location

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