Provider Demographics
NPI:1659845659
Name:OMNI MEDICAL CENTER PLLC
Entity Type:Organization
Organization Name:OMNI MEDICAL CENTER PLLC
Other - Org Name:OMNI COSMETIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:ROLFES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:763-559-4500
Mailing Address - Street 1:935 WAYZATA BLVD E STE 200
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-2513
Mailing Address - Country:US
Mailing Address - Phone:763-559-4500
Mailing Address - Fax:763-559-1733
Practice Address - Street 1:935 WAYZATA BLVD E STE 200
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-2513
Practice Address - Country:US
Practice Address - Phone:763-559-4500
Practice Address - Fax:763-559-1733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-14
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and NeckGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1659845659OtherOTHER INS