MEDICARE: MEDWAY DIAGNOSTIC LABS 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

General Provider Information

NPI Number	:	1871698282
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDWAY DIAGNOSTIC LABS INC

Provider Business Mailing Address
First Line	:	3138 WEST CERMAK ROAD
Second Line	:	SUITE 106
City	:	CHICAGO
State	:	IL
Zip	:	60623-3306
Country	:	US
Telephone Number	:	773-762-4331
Fax Number	:	773-762-4333

Provider Business Practice Location Address
First Line	:	3138 WEST CERMAK ROAD
Second Line	:	SUITE 106
City	:	CHICAGO
State	:	IL
Zip	:	60623-3306
Country	:	US
Telephone Number	:	773-762-4331
Fax Number	:	773-762-4333

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. BALBIR KAUR DHALIWAL
Credential	:
Telephone Number	:	773-762-4331

Provider Enumeration Date	:	09/13/2006
Last Update Date	:	08/22/2020

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