MEDICARE: SOUTH CHICAGO LAB LIMITED

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	207ZP0105X	Clinical Pathology/Laboratory Medicine Physician

General Provider Information

NPI Number	:	1215502349
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH CHICAGO LAB LIMITED

Provider Business Mailing Address
First Line	:	10215 S 84TH AVE
Second Line	:
City	:	PALOS HILLS
State	:	IL
Zip	:	60465-1302
Country	:	US
Telephone Number	:	815-440-9285
Fax Number	:

Provider Business Practice Location Address
First Line	:	8058 S WESTERN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60620-5936
Country	:	US
Telephone Number	:	815-440-9285
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	STEVEN ABU-SHAQRA
Credential	:	PHD
Telephone Number	:	815-440-9285

Provider Enumeration Date	:	05/21/2021
Last Update Date	:	05/21/2021

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Directions to “SOUTH CHICAGO LAB LIMITED ” Practice Location

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