Healthcare Provider Details

I. General information

NPI: 1447911144
Provider Name (Legal Business Name): NORTHSIDE LAB INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2022
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 W OHIO ST
CHICAGO IL
60622-5561
US

IV. Provider business mailing address

1900 W OHIO ST
CHICAGO IL
60622-5561
US

V. Phone/Fax

Practice location:
  • Phone: 872-235-7824
  • Fax:
Mailing address:
  • Phone: 872-235-7824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: SHAIK AHMED
Title or Position: PRESIDENT
Credential:
Phone: 872-235-7824