Provider Demographics
NPI:1376727255
Name:CHICAGO FERTILITY LABORATORY
Entity Type:Organization
Organization Name:CHICAGO FERTILITY LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:W. PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:DMOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:630-954-0054
Mailing Address - Street 1:PO BOX 7451
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-7451
Mailing Address - Country:US
Mailing Address - Phone:630-954-0054
Mailing Address - Fax:
Practice Address - Street 1:2425 W 22ND ST STE 102
Practice Address - Street 2:
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-4643
Practice Address - Country:US
Practice Address - Phone:630-954-0054
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1400699703291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherBCBS