Provider Demographics
NPI:1477504488
Name:OMONDI, PRICE P (DO)
Entity Type:Individual
Prefix:DR
First Name:PRICE
Middle Name:P
Last Name:OMONDI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 HOLLOW VALLEY CT
Mailing Address - Street 2:
Mailing Address - City:CASEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62232-2838
Mailing Address - Country:US
Mailing Address - Phone:217-403-1634
Mailing Address - Fax:
Practice Address - Street 1:1800 E LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3810
Practice Address - Country:US
Practice Address - Phone:217-464-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-100726207P00000X, 207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036100726OtherBLUE SHIELD
IL036100726-5Medicaid
MO1477504488Medicaid
IL036100726-3Medicaid
IL036100726-1Medicaid
IN200233440Medicaid
IL036100726-2Medicaid
KY7100112980Medicaid
ILK05686Medicare PIN
IL036100726OtherBLUE SHIELD
E58806Medicare UPIN
IN200233440Medicaid
ILIL1943008Medicare PIN
IL036100726-1Medicaid
IL206813004Medicare PIN