Provider Demographics
NPI:1114780525
Name:OMNI MEDICAL 360 PLLC
Entity Type:Organization
Organization Name:OMNI MEDICAL 360 PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:LOBOSCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-813-7788
Mailing Address - Street 1:100 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-3519
Mailing Address - Country:US
Mailing Address - Phone:631-813-7788
Mailing Address - Fax:
Practice Address - Street 1:100 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-3519
Practice Address - Country:US
Practice Address - Phone:631-813-7788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty