MEDICARE: NORTHLAKE INTERNATIONAL MEDICAL LABORATORY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory	05137901	IN

General Provider Information

NPI Number	:	1265437818
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHLAKE INTERNATIONAL MEDICAL LABORATORY

Provider Business Mailing Address
First Line	:	234 W 46TH AVE
Second Line	:
City	:	GARY
State	:	IN
Zip	:	46408-3908
Country	:	US
Telephone Number	:	219-985-1315
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 GRANT ST
Second Line	:	STE 201
City	:	GARY
State	:	IN
Zip	:	46404-3439
Country	:	US
Telephone Number	:	219-614-6833
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MRS. PATRICIA DELLDEAN BROWN
Credential	:	C.T. (IAC)
Telephone Number	:	219-985-1315

Provider Enumeration Date	:	06/19/2005
Last Update Date	:	08/22/2020

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