Basic Information
| Provider Information | |||||||||
| NPI: | 1932380086 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OMNI HEALTH SERVICES, LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 74424 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441944424 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 RALSTON AVE | ||||||||
| Address2: | |||||||||
| City: | DEFIANCE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435121396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197836955 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2007 | ||||||||
| LastUpdateDate: | 01/18/2019 | ||||||||
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| AuthorizedOfficialLastName: | PRIBIS | ||||||||
| AuthorizedOfficialFirstName: | ERICA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4198977907 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 612948000 | 01 | OH | DEPARTMENT OF LABOR | OTHER | 000000492483 | 01 | OH | ANTHEM | OTHER | 726416 | 01 | OH | BUCKEYE | OTHER | 2800188 | 05 | OH | MEDICAID | 05267 | 01 | OH | PARAMOUNT | OTHER |