Healthcare Provider Details

I. General information

NPI: 1508452764
Provider Name (Legal Business Name): OMAIMAH SARA MAHRAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2020
Last Update Date: 11/27/2023
Certification Date: 11/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5841 S MARYLAND AVE
CHICAGO IL
60637-1443
US

IV. Provider business mailing address

150 HARVESTER DR STE 300
BURR RIDGE IL
60527-5965
US

V. Phone/Fax

Practice location:
  • Phone: 773-702-1000
  • Fax:
Mailing address:
  • Phone: 773-702-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.022322
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number209.022322
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: