Provider Demographics
NPI:1336291236
Name:JUSTICE MED LAB
Entity Type:Organization
Organization Name:JUSTICE MED LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTOU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-563-0330
Mailing Address - Street 1:9050 W 81ST ST
Mailing Address - Street 2:
Mailing Address - City:JUSTICE
Mailing Address - State:IL
Mailing Address - Zip Code:60458-1350
Mailing Address - Country:US
Mailing Address - Phone:708-594-3500
Mailing Address - Fax:708-594-5171
Practice Address - Street 1:9050 W 81ST ST
Practice Address - Street 2:
Practice Address - City:JUSTICE
Practice Address - State:IL
Practice Address - Zip Code:60458-1350
Practice Address - Country:US
Practice Address - Phone:708-594-3500
Practice Address - Fax:708-594-5171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14D0982127291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01629953OtherBCBS
IL01629953OtherBCBS