MEDICARE: DIAGNOSTIC MEDICAL LABORATORY, 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	246QL0900X	Laboratory Management Specialist/Technologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376685016
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIAGNOSTIC MEDICAL LABORATORY, INC.

Provider Business Mailing Address
First Line	:	4554 N. BROADWAY STREET
Second Line	:	SUITE 317
City	:	CHICAGO
State	:	IL
Zip	:	60640-5642
Country	:	US
Telephone Number	:	773-255-4959
Fax Number	:	773-506-0269

Provider Business Practice Location Address
First Line	:	4554 N. BROADWAY STREET
Second Line	:	SUITE 317
City	:	CHICAGO
State	:	IL
Zip	:	60640-5642
Country	:	US
Telephone Number	:	773-255-4959
Fax Number	:	773-506-0269

Authorized Official
Title or Position	:	LABORATORY DIRECTOR AND OWNER
Name	:	DR. JOSEPH S TENGBEH SR.
Credential	:	MD.
Telephone Number	:	773-255-4959

Provider Enumeration Date	:	02/12/2007
Last Update Date	:	02/22/2012

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