Provider Demographics
NPI:1518244573
Name:OMNI HEALTH PC
Entity Type:Organization
Organization Name:OMNI HEALTH PC
Other - Org Name:LINCOLN SQUARE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:M.D
Authorized Official - Prefix:DR
Authorized Official - First Name:ZAKI
Authorized Official - Middle Name:
Authorized Official - Last Name:SIDDIQUI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-989-3344
Mailing Address - Street 1:2501 W LAWRENCE AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-2958
Mailing Address - Country:US
Mailing Address - Phone:773-989-3344
Mailing Address - Fax:773-989-8458
Practice Address - Street 1:2501 W LAWRENCE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-2958
Practice Address - Country:US
Practice Address - Phone:773-989-3344
Practice Address - Fax:773-989-8458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-04
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036122637207Q00000X
IL036100955208000000X
IL0361268882080P0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental DisabilitiesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036100955Medicaid
IL036100955Medicaid