Healthcare Provider Details

I. General information

NPI: 1376866897
Provider Name (Legal Business Name): PHYSICIANS DERMPATH LABORATORY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2010
Last Update Date: 11/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 N. RENAISSANCE DR. SUITE 204
PARK RIDGE IL
60068-1330
US

IV. Provider business mailing address

1420 N. RENAISSANCE DR. SUITE 204
PARK RIDGE IL
60068-1330
US

V. Phone/Fax

Practice location:
  • Phone: 847-768-2440
  • Fax: 847-768-2443
Mailing address:
  • Phone: 847-768-2440
  • Fax: 847-768-2443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID A. LORBER
Title or Position: PRESIDENT
Credential: MD
Phone: 847-675-9711