MEDICARE: DOCTOR'S DATA, 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	14D0646470	IL

General Provider Information

NPI Number	:	1750362224
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOCTOR'S DATA, INC.

Provider Business Mailing Address
First Line	:	3755 ILLINOIS AVE
Second Line	:
City	:	ST CHARLES
State	:	IL
Zip	:	60174-2420
Country	:	US
Telephone Number	:	630-377-8139
Fax Number	:	630-587-7860

Provider Business Practice Location Address
First Line	:	3755 ILLINOIS AVE
Second Line	:
City	:	ST CHARLES
State	:	IL
Zip	:	60174-2420
Country	:	US
Telephone Number	:	630-377-8139
Fax Number	:	630-587-7860

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	DARRELL S HICKOK
Credential	:
Telephone Number	:	630-377-8139

Provider Enumeration Date	:	11/10/2005
Last Update Date	:	03/30/2015

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