Healthcare Provider Details

I. General information

NPI: 1699025239
Provider Name (Legal Business Name): OMNI PRIMARY CARE AND AESTHETIC MEDICINE SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2012
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 N LINCOLN AVE
LINCOLNWOOD IL
60712-3925
US

IV. Provider business mailing address

6501 N LINCOLN AVE
LINCOLNWOOD IL
60712-3925
US

V. Phone/Fax

Practice location:
  • Phone: 847-242-1001
  • Fax: 847-739-7219
Mailing address:
  • Phone: 847-242-1001
  • Fax: 847-739-7219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number036122637
License Number StateIL

VIII. Authorized Official

Name: DR. JUWARIA OSMANI SIDDIQUI
Title or Position: DOCTOR
Credential: M.D
Phone: 847-242-1001