MEDICARE: OMEGA HOSPICE & PALLIATIVE CARE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251G00000X	Community Based Hospice Care Agency	2002590	IL

General Provider Information

NPI Number	:	1063615920
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMEGA HOSPICE & PALLIATIVE CARE, LLC

Provider Business Mailing Address
First Line	:	1717 HOWARD ST
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60202-3735
Country	:	US
Telephone Number	:	847-425-9089
Fax Number	:	847-425-9091

Provider Business Practice Location Address
First Line	:	1717 HOWARD ST
Second Line	:
City	:	EVANSTON
State	:	IL
Zip	:	60202-3735
Country	:	US
Telephone Number	:	847-425-9089
Fax Number	:	847-425-9091

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. EDWARD LEE OLLER JR.
Credential	:	R.N.
Telephone Number	:	847-425-9089

Provider Enumeration Date	:	06/07/2007
Last Update Date	:	08/22/2020

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