Healthcare Provider Details

I. General information

NPI: 1558635516
Provider Name (Legal Business Name): PARK RIDGE LAB INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2012
Last Update Date: 03/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 N NORTHWEST HWY STE 102
PARK RIDGE IL
60068-2349
US

IV. Provider business mailing address

950 N NORTHWEST HWY STE 102
PARK RIDGE IL
60068-2349
US

V. Phone/Fax

Practice location:
  • Phone: 847-696-9900
  • Fax: 630-952-1447
Mailing address:
  • Phone: 847-696-9900
  • Fax: 630-952-1447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: DR. SAM SPERON
Title or Position: PRESIDENT
Credential: MD
Phone: 847-696-9900