Provider Demographics
NPI:1881082337
Name:OMNICARE PHYSICIAN PROVIDERS LLC
Entity type:Organization
Organization Name:OMNICARE PHYSICIAN PROVIDERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NICK
Authorized Official - Middle Name:
Authorized Official - Last Name:MAJECKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-573-5017
Mailing Address - Street 1:405 STATE HIGHWAY 121 BYP
Mailing Address - Street 2:SUITE A250
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-8214
Mailing Address - Country:US
Mailing Address - Phone:469-573-5017
Mailing Address - Fax:888-431-4912
Practice Address - Street 1:405 STATE HIGHWAY 121 BYP
Practice Address - Street 2:SUITE A250
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-8214
Practice Address - Country:US
Practice Address - Phone:469-573-5017
Practice Address - Fax:888-431-4912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-07
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC18226Medicare UPIN
TXTX104039Medicare PIN
TX131879208Medicaid