MEDICARE: NORTHERN ILLINOIS CLINICAL LABORATORY, LTD.

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	:	1598734022
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHERN ILLINOIS CLINICAL LABORATORY, LTD.

Provider Business Mailing Address
First Line	:	306 ERA DR
Second Line	:
City	:	NORTHBROOK
State	:	IL
Zip	:	60062-1834
Country	:	US
Telephone Number	:	847-509-9779
Fax Number	:	847-509-9255

Provider Business Practice Location Address
First Line	:	7531 S STONY ISLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-3954
Country	:	US
Telephone Number	:	773-947-7660
Fax Number	:	773-947-0482

Authorized Official
Title or Position	:	GENERAL MANAGER
Name	:	MRS. ANNA M WELDER
Credential	:	MT (ASCP)
Telephone Number	:	847-509-9779

Provider Enumeration Date	:	03/16/2006
Last Update Date	:	08/22/2020

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