MEDICARE: DOCTORS GENERAL LABORATORY CORP

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	001	IL
2	291U00000X	Clinical Medical Laboratory	14D0419924	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0050000480	OTHER	IL	BLUE CROSS ID
2	690009492	OTHER	IL	RAIL ROAD ID

General Provider Information

NPI Number	:	1851392617
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOCTORS GENERAL LABORATORY CORP

Provider Business Mailing Address
First Line	:	9243 S ROBERTS RD
Second Line	:
City	:	HICKORY HILLS
State	:	IL
Zip	:	60457-2079
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	59 OGDEN AVE
Second Line	:
City	:	CLARENDON HILLS
State	:	IL
Zip	:	60514-1026
Country	:	US
Telephone Number	:	708-599-5666
Fax Number	:	708-599-8737

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. MAHENDRA H PATEL
Credential	:
Telephone Number	:	708-599-5666

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	07/21/2022

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