Provider Demographics
NPI:1386136315
Name:ALPHA OMEGA MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:ALPHA OMEGA MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST/FOOT AND ANKLE SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMON
Authorized Official - Middle Name:
Authorized Official - Last Name:HANNA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:201-925-1105
Mailing Address - Street 1:5750 RUSACK DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-8016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36503 US HIGHWAY 19 N
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684
Practice Address - Country:US
Practice Address - Phone:201-925-1105
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-05
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME131622207Q00000X
FLPO3900213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty