Provider Demographics
NPI:1275716540
Name:OMNICARE MEDICAL CLINIC,INC
Entity Type:Organization
Organization Name:OMNICARE MEDICAL CLINIC,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:KANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-955-7117
Mailing Address - Street 1:1481 S KING ST
Mailing Address - Street 2:SUITE 422
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-2506
Mailing Address - Country:US
Mailing Address - Phone:808-955-7117
Mailing Address - Fax:808-955-7138
Practice Address - Street 1:1481 S KING ST
Practice Address - Street 2:SUITE 422
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-2506
Practice Address - Country:US
Practice Address - Phone:808-955-7117
Practice Address - Fax:808-955-7138
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI9018208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIH0000BDXTLMedicare PIN