1689862666 NPI number — OMNI FOOTCARE ASSOCIATES, PC

Table of content: (NPI 1689862666)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689862666 NPI number — OMNI FOOTCARE ASSOCIATES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OMNI FOOTCARE ASSOCIATES, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689862666
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13811 19 MILE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STERLING HEIGHTS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48313-2705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-247-0840
Provider Business Mailing Address Fax Number:
586-247-7668

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13811 19 MILE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STERLING HEIGHTS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48313-2705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-247-0840
Provider Business Practice Location Address Fax Number:
586-247-7668
Provider Enumeration Date:
10/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WOLF
Authorized Official First Name:
ARNOLD
Authorized Official Middle Name:
BRYAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
586-247-0840

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  AW001164 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 83069B . This is a "HAP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: AW001164 . This is a "STATE LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 870453 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: C7479 . This is a "M CARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4662672 . This is a "AETNA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1710645 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 480E021060 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4885050380 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: DE4368 . This is a "RAILROAD MEDICARE PART B" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 104435 . This is a "GREAT LAKES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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