=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710516455
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHICAGO LABORATORY CONSULTANT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2020
-----------------------------------------------------
Last Update Date | 07/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 N WABASH AVE STE 1605
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60602-3055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 872-201-8236
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2434 E DEMPSTER ST STE 109
-----------------------------------------------------
City | DES PLAINES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60016-5339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 872-201-8236
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO & SCIENTIFIC DIRECTOR
-----------------------------------------------------
Name | SYED HAQUE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 872-201-8236
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------