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
State | License ID | Taxonomies |
---|---|---|
PA | MD056591L | 2086S0102X, 2086S0127X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Not Answered | 2086S0102X | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
Not Answered | 2086S0127X | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
PA | E15171 | Medicare UPIN | |
PA | 0000471719 | Medicare ID - Type Unspecified |