Healthcare Provider Details

I. General information

NPI: 1073978631
Provider Name (Legal Business Name): SOUTHSHORE MEDI LAB INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2015
Last Update Date: 12/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4651 W 79TH ST STE 204
CHICAGO IL
60652-1775
US

IV. Provider business mailing address

4651 W 79TH ST STE 204
CHICAGO IL
60652-1775
US

V. Phone/Fax

Practice location:
  • Phone: 773-585-0480
  • Fax: 773-585-0482
Mailing address:
  • Phone: 773-585-0480
  • Fax: 773-585-0482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number14D2104608
License Number StateIL

VIII. Authorized Official

Name: MR. ASHFAQ MUHAMMAD
Title or Position: PRESIDENT
Credential:
Phone: 773-585-0480