Provider Demographics
NPI:1033258397
Name:OMERT, LAUREL ANN (MD)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:ANN
Last Name:OMERT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9249 LINCOLNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60203-1609
Mailing Address - Country:US
Mailing Address - Phone:847-763-0761
Mailing Address - Fax:847-864-0353
Practice Address - Street 1:9249 LINCOLNWOOD DR
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60203-1609
Practice Address - Country:US
Practice Address - Phone:847-763-0761
Practice Address - Fax:847-864-0353
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD056591L2086S0102X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Not Answered2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAE15171Medicare UPIN
PA0000471719Medicare ID - Type Unspecified