Provider Demographics
NPI:1699025239
Name:OMNI PRIMARY CARE AND AESTHETIC MEDICINE SC
Entity type:Organization
Organization Name:OMNI PRIMARY CARE AND AESTHETIC MEDICINE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JUWARIA
Authorized Official - Middle Name:OSMANI
Authorized Official - Last Name:SIDDIQUI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-242-1001
Mailing Address - Street 1:6501 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-3925
Mailing Address - Country:US
Mailing Address - Phone:847-242-1001
Mailing Address - Fax:847-739-7219
Practice Address - Street 1:6501 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:LINCOLNWOOD
Practice Address - State:IL
Practice Address - Zip Code:60712-3925
Practice Address - Country:US
Practice Address - Phone:847-242-1001
Practice Address - Fax:847-739-7219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-11
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036122637207QA0000X
208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036122637Medicaid