Healthcare Provider Details

I. General information

NPI: 1407152366
Provider Name (Legal Business Name): HESHAM OMAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2011
Last Update Date: 11/17/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E NORRIS DR
OTTAWA IL
61350-1604
US

IV. Provider business mailing address

36123 SCHOOLCRAFT RD
LIVONIA MI
48150-1216
US

V. Phone/Fax

Practice location:
  • Phone: 815-431-5380
  • Fax: 815-431-5672
Mailing address:
  • Phone: 734-793-6140
  • Fax: 865-560-8948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01081207
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number65482
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036.144356
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: