Healthcare Provider Details

I. General information

NPI: 1487558417
Provider Name (Legal Business Name): OMOD HALLY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5228 N SHERIDAN RD
CHICAGO IL
60640-2537
US

IV. Provider business mailing address

50005TH AVE
HINES IL
60141
US

V. Phone/Fax

Practice location:
  • Phone: 773-372-9477
  • Fax:
Mailing address:
  • Phone: 708-202-8387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number041.401278
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: