Healthcare Provider Details

I. General information

NPI: 1639628225
Provider Name (Legal Business Name): SCOTTLAB, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2016
Last Update Date: 08/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 W 156TH ST STE 206A
HARVEY IL
60426
US

IV. Provider business mailing address

71 W 156TH ST STE 206A
HARVEY IL
60426-4262
US

V. Phone/Fax

Practice location:
  • Phone: 312-794-7772
  • Fax: 773-649-3138
Mailing address:
  • Phone: 773-649-3099
  • Fax: 773-649-3138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number14D2118158
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number14D2118158
License Number StateIL

VIII. Authorized Official

Name: RANA S SAIFAN
Title or Position: ASSISTANT
Credential: STAFF
Phone: 773-649-3099