MEDICARE: ELITE PATHOLOGY LAB INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZC0006X	Clinical Pathology Physician

General Provider Information

NPI Number	:	1063927572
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELITE PATHOLOGY LAB INC

Provider Business Mailing Address
First Line	:	PO BOX 3363
Second Line	:
City	:	OAK BROOK
State	:	IL
Zip	:	60522-3363
Country	:	US
Telephone Number	:	630-889-9889
Fax Number	:

Provider Business Practice Location Address
First Line	:	3744 W NORTH AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-4727
Country	:	US
Telephone Number	:	630-889-9889
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DAVID CHUA
Credential	:	MD
Telephone Number	:	630-889-9889

Provider Enumeration Date	:	12/06/2017
Last Update Date	:	12/06/2017

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