Provider Demographics
NPI:1073874145
Name:OMNICARE MEDICAL CENTER INC
Entity Type:Organization
Organization Name:OMNICARE MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OWEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:FRASER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-578-9142
Mailing Address - Street 1:1805 W COLONIAL DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-7013
Mailing Address - Country:US
Mailing Address - Phone:407-578-9142
Mailing Address - Fax:407-578-8616
Practice Address - Street 1:1805 W COLONIAL DR
Practice Address - Street 2:SUITE A
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-7013
Practice Address - Country:US
Practice Address - Phone:407-578-9142
Practice Address - Fax:407-578-8616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-05
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME30256261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL58757500Medicaid
FL58757500Medicaid