MEDICARE: OMNI LABORATORY SERVICES

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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1063991735
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMNI LABORATORY SERVICES

Provider Business Mailing Address
First Line	:	5866 N LINCOLN AVE
Second Line	:	STE 103
City	:	CHICAGO
State	:	IL
Zip	:	60659-4632
Country	:	US
Telephone Number	:	773-200-8059
Fax Number	:

Provider Business Practice Location Address
First Line	:	5866 N LINCOLN AVE
Second Line	:	STE 103
City	:	CHICAGO
State	:	IL
Zip	:	60659-4632
Country	:	US
Telephone Number	:	773-200-8059
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	GULAM TAHA SIDDIQUE
Credential	:
Telephone Number	:	773-200-8059

Provider Enumeration Date	:	08/13/2018
Last Update Date	:	03/13/2024

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