MEDICARE: COUNTY DIAGNOSTIC INCORPORATION

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

General Provider Information

NPI Number	:	1407517105
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNTY DIAGNOSTIC INCORPORATION

Provider Business Mailing Address
First Line	:	5129 W DEVON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60646-4217
Country	:	US
Telephone Number	:	773-255-0605
Fax Number	:

Provider Business Practice Location Address
First Line	:	5129 W DEVON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60646-4217
Country	:	US
Telephone Number	:	773-255-0605
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	FAREED KHAN
Credential	:
Telephone Number	:	773-255-0605

Provider Enumeration Date	:	01/05/2022
Last Update Date	:	06/23/2022

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Directions to “COUNTY DIAGNOSTIC INCORPORATION ” Practice Location

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