Healthcare Provider Details

I. General information

NPI: 1710587852
Provider Name (Legal Business Name): EXPRESS MEDICAL LABS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2020
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9830 RIDGELAND AVE STE 115
CHICAGO RIDGE IL
60415-2667
US

IV. Provider business mailing address

9830 RIDGELAND AVE STE 115
CHICAGO RIDGE IL
60415-2667
US

V. Phone/Fax

Practice location:
  • Phone: 708-336-9002
  • Fax: 708-229-2101
Mailing address:
  • Phone: 708-336-9002
  • Fax: 708-229-2101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: DR. STEVEN ABU-SHAQRA
Title or Position: LAB DIRECTOR
Credential: PHD
Phone: 815-440-9285