Provider Demographics
NPI:1952852121
Name:OMNI FAMILY MEDICAL SC
Entity Type:Organization
Organization Name:OMNI FAMILY MEDICAL SC
Other - Org Name:OMNI FAMILY MEDICAL SC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MURTIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANT-ACQUAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-374-9575
Mailing Address - Street 1:7810 W GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53223-4518
Mailing Address - Country:US
Mailing Address - Phone:414-586-9255
Mailing Address - Fax:
Practice Address - Street 1:7810 W GOOD HOPE RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53223-4518
Practice Address - Country:US
Practice Address - Phone:414-586-9255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6454820207R00000X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No305S00000XManaged Care OrganizationsPoint of ServiceGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK100268237Medicare UPIN