Healthcare Provider Details

I. General information

NPI: 1144202003
Provider Name (Legal Business Name): MEDSTAR LABORATORY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 09/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4531 HARRISON ST
HILLSIDE IL
60162-1614
US

IV. Provider business mailing address

4531 HARRISON ST
HILLSIDE IL
60162-1614
US

V. Phone/Fax

Practice location:
  • Phone: 708-488-1000
  • Fax: 708-488-1831
Mailing address:
  • Phone: 708-488-1000
  • Fax: 708-488-1831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number14D0945905
License Number StateIL

VIII. Authorized Official

Name: RAJ N PATEL
Title or Position: VICE PRESIDENT
Credential:
Phone: 708-488-1000