Provider Demographics
NPI:1265592125
Name:OMNIHEALTH MEDICAL GROUP, P.A.
Entity type:Organization
Organization Name:OMNIHEALTH MEDICAL GROUP, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GEOFFREY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:704-784-4445
Mailing Address - Street 1:70 LAKE CONCORD ROAD NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-3057
Mailing Address - Country:US
Mailing Address - Phone:704-784-4445
Mailing Address - Fax:704-784-4335
Practice Address - Street 1:70 LAKE CONCORD ROAD NE
Practice Address - Street 2:SUITE 100
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-3057
Practice Address - Country:US
Practice Address - Phone:704-784-4445
Practice Address - Fax:704-784-4335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28841174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
6404820001Medicare NSC
C81831Medicare UPIN
2331643Medicare PIN
NCC81831Medicare UPIN