Provider Demographics
NPI:1811083868
Name:OMNIMED LLC
Entity type:Organization
Organization Name:OMNIMED LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MARKETING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-329-3136
Mailing Address - Street 1:9720 S TRYON ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-6578
Mailing Address - Country:US
Mailing Address - Phone:704-588-7362
Mailing Address - Fax:704-588-9127
Practice Address - Street 1:9720 S TRYON ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-6578
Practice Address - Country:US
Practice Address - Phone:704-588-7362
Practice Address - Fax:704-588-9127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC015V0OtherBLUE CROSS BLUE SHIELD NC
NC5766710002Medicare NSC