Provider Demographics
NPI:1740392687
Name:OM JAY GAYATRI MA INC
Entity type:Organization
Organization Name:OM JAY GAYATRI MA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:IN CHARGE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GHANSHYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-768-7868
Mailing Address - Street 1:2315 E 93RD ST
Mailing Address - Street 2:STE 215
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-3936
Mailing Address - Country:US
Mailing Address - Phone:773-768-7868
Mailing Address - Fax:773-768-7869
Practice Address - Street 1:2315 E 93RD ST
Practice Address - Street 2:STE 215
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-3936
Practice Address - Country:US
Practice Address - Phone:773-768-7868
Practice Address - Fax:773-768-7869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
IL0540149733336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2021364OtherPK
IL=========001Medicaid
2021364OtherPK