Basic Information
| Provider Information | |||||||||
| NPI: | 1528161619 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OHNMACHT | ||||||||
| FirstName: | GALEN | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 965 RIDGE LAKE BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209446 | ||||||||
| CountryCode: | US | ||||||||
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| FaxNumber: | 9012278591 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 MARSHALL ST STE 104 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392021663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019696404 | ||||||||
| FaxNumber: | 6019734541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 08/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | D0055464 | MD | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 28001 | MS | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 165767 | 01 | MD | MEDICARE PTAN | OTHER | 5780 | 01 | MD | BRAVO/ELDER HEALTH | OTHER | D0055464 | 01 | MD | STATE LICENSE | OTHER | O242-0021 | 01 | DC | CARE FIRST BLUE CROSS | OTHER | 7377893 | 01 | MD | AETNA PPO | OTHER | 1395992 | 01 | MD | AETNA HMO | OTHER | 200431 | 01 | MD | JOHNS HOPKINS HEALTH CARE | OTHER | 314995 | 01 | MD | AMERIGROUP | OTHER | 8892097 | 01 | MD | CIGNA | OTHER | 411280600 | 05 | MD | MEDICAID | 888913-02 | 01 | MD | CARE FIRST BLUE CROSS | OTHER |