Provider Demographics
NPI:1376685016
Name:DIAGNOSTIC MEDICAL LABORATORY, INC.
Entity Type:Organization
Organization Name:DIAGNOSTIC MEDICAL LABORATORY, INC.
Other - Org Name:DIAGNOSTIC MEDICAL LABORATORY, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LABORATORY DIRECTOR AND OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:S
Authorized Official - Last Name:TENGBEH
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:773-255-4959
Mailing Address - Street 1:4554 N. BROADWAY STREET
Mailing Address - Street 2:SUITE 317
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5642
Mailing Address - Country:US
Mailing Address - Phone:773-255-4959
Mailing Address - Fax:773-506-0269
Practice Address - Street 1:4554 N. BROADWAY STREET
Practice Address - Street 2:SUITE 317
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5642
Practice Address - Country:US
Practice Address - Phone:773-255-4959
Practice Address - Fax:773-506-0269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246QL0900XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyLaboratory ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL20388576001Medicaid
IL213202Medicare UPIN