MEDICARE: OMER H WHARTON-ALI MD A PROFESSIONAL CORPORATION

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	3863	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912992983
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMER H WHARTON-ALI MD A PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	PO BOX 364479
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89036-8479
Country	:	US
Telephone Number	:	702-399-3404
Fax Number	:	702-399-1819

Provider Business Practice Location Address
First Line	:	1703 CIVIC CENTER DR #1B
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89030-7273
Country	:	US
Telephone Number	:	702-399-3404
Fax Number	:	702-399-1819

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. OMER H WHARTON-ALI
Credential	:	MD
Telephone Number	:	702-399-3404

Provider Enumeration Date	:	09/15/2005
Last Update Date	:	01/08/2008

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