MEDICARE: NORTHSHORE CLINICAL LABORATORIES 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	291U00000X	Clinical Medical Laboratory

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3580499	OTHER	IL	UHC
2	5847070	OTHER	IL	AETNA
3	0001621417	OTHER	IL	BCBS

General Provider Information

NPI Number	:	1477671345
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHSHORE CLINICAL LABORATORIES INC

Provider Business Mailing Address
First Line	:	4751 N KEDZIE AVE FL 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-4420
Country	:	US
Telephone Number	:	773-570-6510
Fax Number	:

Provider Business Practice Location Address
First Line	:	4751 N KEDZIE AVE FL 1
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-4420
Country	:	US
Telephone Number	:	773-570-6510
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MEENA MOHINDRA
Credential	:
Telephone Number	:	773-570-6510

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	10/19/2021

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