Provider Demographics
NPI:1912019340
Name:OMELIA, KEVIN MICHAEL (DC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHAEL
Last Name:OMELIA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2026 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103
Mailing Address - Country:US
Mailing Address - Phone:215-569-1900
Mailing Address - Fax:215-569-2776
Practice Address - Street 1:2026 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103
Practice Address - Country:US
Practice Address - Phone:215-569-1900
Practice Address - Fax:215-569-2776
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC8637111N00000X
PADN003994133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1180341OtherHORIZON BLUE CROSS BLUE SHIELD OF NJ
11913763OtherCAQH ID
PA2622003OtherHIGHMARK BLUE SHIELD
PA2622003OtherHIGHMARK BLUE SHIELD
PA242734YHVMMedicare UPIN