MEDICARE: IMPALA EXPRESS CLINICAL LABORATORY SERVICE INC

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	14D2018991	IL

General Provider Information

NPI Number	:	1346530201
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPALA EXPRESS CLINICAL LABORATORY SERVICE INC

Provider Business Mailing Address
First Line	:	845 N MICHIGAN AVE STE 944E
Second Line	:	845 N. MICHIGAN AVE, SUITE # 944-E
City	:	CHICAGO
State	:	IL
Zip	:	60611-2213
Country	:	US
Telephone Number	:	312-202-0328
Fax Number	:	312-202-0320

Provider Business Practice Location Address
First Line	:	845 N MICHIGAN AVE STE 944E
Second Line	:	845 N. MICHIGAN AVE, SUITE # 944-E
City	:	CHICAGO
State	:	IL
Zip	:	60611-2213
Country	:	US
Telephone Number	:	312-202-0328
Fax Number	:	312-202-0320

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. ALEMAYEHU M GEBRESELLASSIE
Credential	:
Telephone Number	:	847-951-5168

Provider Enumeration Date	:	04/12/2011
Last Update Date	:	06/12/2012

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