Provider Demographics
NPI:1710563010
Name:OMNI MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:OMNI MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DYLON
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-705-1308
Mailing Address - Street 1:4153 FLAT SHOALS PKWY STE 300C
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-4106
Mailing Address - Country:US
Mailing Address - Phone:404-386-6510
Mailing Address - Fax:404-500-2097
Practice Address - Street 1:4153 FLAT SHOALS PKWY STE 300C
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-4106
Practice Address - Country:US
Practice Address - Phone:404-386-6510
Practice Address - Fax:404-500-2097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-18
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1649205642Medicaid