Provider Demographics
NPI:1356318059
Name:OMER, IMAD (MD)
Entity Type:Individual
Prefix:
First Name:IMAD
Middle Name:
Last Name:OMER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6799 GREAT OAKS RD STE 250
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38138-2584
Mailing Address - Country:US
Mailing Address - Phone:901-685-3490
Mailing Address - Fax:901-685-3499
Practice Address - Street 1:6029 WALNUT GROVE RD # C002
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2112
Practice Address - Country:US
Practice Address - Phone:901-685-3490
Practice Address - Fax:901-685-3499
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD36446207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04026851Medicaid
MS09016197Medicaid
TN4043619OtherBCBST
TN3721649Medicaid
TN3876262Medicaid
TN3876263Medicare PIN
G78945Medicare UPIN
TN3721649Medicaid
MS09016197Medicaid