Provider Demographics
NPI:1417185182
Name:OMMEN, BRIAN M
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:M
Last Name:OMMEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7872 CENTURY BLVD
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317
Mailing Address - Country:US
Mailing Address - Phone:952-448-9081
Mailing Address - Fax:952-448-9088
Practice Address - Street 1:7872 CENTURY BLVD
Practice Address - Street 2:
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317-8005
Practice Address - Country:US
Practice Address - Phone:952-448-9081
Practice Address - Fax:952-448-9088
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8474225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN650002427Medicare PIN
SDS103377Medicare PIN