MEDICARE: OMNIMED LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	208100000X	Physical Medicine & Rehabilitation Physician
2	2083P0500X	Preventive Medicine/Occupational Environmental Medicine Physician
3	225100000X	Physical Therapist
4	247100000X	Radiologic Technologist
5	363L00000X	Nurse Practitioner
6	207P00000X	Emergency Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	015V0	OTHER	NC	BLUE CROSS BLUE SHIELD NC

General Provider Information

NPI Number	:	1811083868
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMNIMED LLC

Provider Business Mailing Address
First Line	:	9720 S TRYON ST
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28273-6578
Country	:	US
Telephone Number	:	704-588-7362
Fax Number	:	704-588-9127

Provider Business Practice Location Address
First Line	:	9720 S TRYON ST
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28273-6578
Country	:	US
Telephone Number	:	704-588-7362
Fax Number	:	704-588-9127

Authorized Official
Title or Position	:	MARKETING DIRECTOR
Name	:	KRISTA BURNS
Credential	:
Telephone Number	:	803-329-3136

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	04/29/2010

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Directions to “OMNIMED LLC ” Practice Location

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