Provider Demographics
NPI:1417380106
Name:GABACHIEF MEDICAL INC
Entity Type:Organization
Organization Name:GABACHIEF MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-420-0063
Mailing Address - Street 1:4916 N CRESCENT AVE
Mailing Address - Street 2:
Mailing Address - City:NORRIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60706-3108
Mailing Address - Country:US
Mailing Address - Phone:708-420-0063
Mailing Address - Fax:
Practice Address - Street 1:8343 W LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:NORRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60706-3129
Practice Address - Country:US
Practice Address - Phone:708-420-0063
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-16
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
291U00000X
IL203.001595332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14D2209774Medicaid