MEDICARE: OMNI DIAGNOSTIC LABORATORY INC

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	:	1154022200
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMNI DIAGNOSTIC LABORATORY INC

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

Provider Business Practice Location Address
First Line	:	5866 N LINCOLN AVE STE 103
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-4632
Country	:	US
Telephone Number	:	773-574-8743
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	MOHAMMED AZHERUDDIN
Credential	:
Telephone Number	:	773-943-2487

Provider Enumeration Date	:	03/15/2023
Last Update Date	:	06/10/2025

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