Healthcare Provider Details

I. General information

NPI: 1497199350
Provider Name (Legal Business Name): PHYSICIAN DIAGNOSTIC AND PATHOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2013
Last Update Date: 05/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7530 W COLLEGE DR
PALOS HEIGHTS IL
60463-1196
US

IV. Provider business mailing address

10400 SOUTHWEST HWY LOWER LEVEL
CHICAGO RIDGE IL
60415-1367
US

V. Phone/Fax

Practice location:
  • Phone: 708-361-8162
  • Fax: 708-361-8173
Mailing address:
  • Phone: 708-590-8770
  • Fax: 708-428-4277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT S FIRLIT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 708-361-0840