Healthcare Provider Details

I. General information

NPI: 1063927572
Provider Name (Legal Business Name): ELITE PATHOLOGY LAB INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2017
Last Update Date: 12/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3744 W NORTH AVE
CHICAGO IL
60647-4727
US

IV. Provider business mailing address

PO BOX 3363
OAK BROOK IL
60522-3363
US

V. Phone/Fax

Practice location:
  • Phone: 630-889-9889
  • Fax:
Mailing address:
  • Phone: 630-889-9889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID CHUA
Title or Position: PRESIDENT
Credential: MD
Phone: 630-889-9889