Provider Demographics
NPI:1013658467
Name:OMEGA PHYSICIAN PRACTICE LLC
Entity type:Organization
Organization Name:OMEGA PHYSICIAN PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ANESTHESIOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RUDOLPH
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD MPH
Authorized Official - Phone:205-317-8437
Mailing Address - Street 1:3927 CONCORD WALK DR SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-3659
Mailing Address - Country:US
Mailing Address - Phone:205-317-8437
Mailing Address - Fax:
Practice Address - Street 1:1300 RIDENOUR BLVD NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-4501
Practice Address - Country:US
Practice Address - Phone:770-702-1806
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty