Basic Information
| Provider Information | |||||||||
| NPI: | 1912019340 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OMELIA | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | DC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2026 CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155691900 | ||||||||
| FaxNumber: | 2155692776 | ||||||||
| Practice Location | |||||||||
| Address1: | 2026 CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155691900 | ||||||||
| FaxNumber: | 2155692776 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 06/10/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | DC8637 | PA | Y | Chiropractic Providers | Chiropractor | 133N00000X | DN003994 | PA | N | Dietary & Nutritional Service Providers | Nutritionist | 133V00000X | DN003994 | PA | N | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 1180341 | 01 | NJ | HORIZON BLUE CROSS BLUE SHIELD OF NJ | OTHER | 11913763 | 01 | CAQH ID | OTHER | 2622003 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER |