MEDICARE: MODERN LABORATORY INCORPORATED

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	291U00000X	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	14D1079331	OTHER	IL	CLIA
2	216691	OTHER	IL	PTAN

General Provider Information

NPI Number	:	1366612731
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN LABORATORY INCORPORATED

Provider Business Mailing Address
First Line	:	1793 BLOOMINGDALE RD STE 1
Second Line	:
City	:	GLENDALE HEIGHTS
State	:	IL
Zip	:	60139-3800
Country	:	US
Telephone Number	:	630-933-8101
Fax Number	:	630-933-8105

Provider Business Practice Location Address
First Line	:	1793 BLOOMINGDALE RD STE 1
Second Line	:
City	:	GLENDALE HEIGHTS
State	:	IL
Zip	:	60139-3800
Country	:	US
Telephone Number	:	630-933-8101
Fax Number	:	630-933-8105

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. PRASANTA K GHOSE
Credential	:
Telephone Number	:	630-933-8101

Provider Enumeration Date	:	03/03/2008
Last Update Date	:	09/18/2014

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