Provider Demographics
NPI:1144202003
Name:MEDSTAR LABORATORY, INC
Entity Type:Organization
Organization Name:MEDSTAR LABORATORY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAJ
Authorized Official - Middle Name:N
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-488-1000
Mailing Address - Street 1:4531 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:HILLSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60162-1614
Mailing Address - Country:US
Mailing Address - Phone:708-488-1000
Mailing Address - Fax:708-488-1831
Practice Address - Street 1:4531 HARRISON ST
Practice Address - Street 2:
Practice Address - City:HILLSIDE
Practice Address - State:IL
Practice Address - Zip Code:60162-1614
Practice Address - Country:US
Practice Address - Phone:708-488-1000
Practice Address - Fax:708-488-1831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-16
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14D0945905291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
1144202003OtherNPI
506110OtherPTAN
1144202003OtherNPI