Provider Demographics
NPI:1598734022
Name:NORTHERN ILLINOIS CLINICAL LABORATORY, LTD.
Entity Type:Organization
Organization Name:NORTHERN ILLINOIS CLINICAL LABORATORY, LTD.
Other - Org Name:PROPATH LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WELDER
Authorized Official - Suffix:
Authorized Official - Credentials:MT (ASCP)
Authorized Official - Phone:847-509-9779
Mailing Address - Street 1:306 ERA DR
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-1834
Mailing Address - Country:US
Mailing Address - Phone:847-509-9779
Mailing Address - Fax:847-509-9255
Practice Address - Street 1:7531 S STONY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-3954
Practice Address - Country:US
Practice Address - Phone:773-947-7660
Practice Address - Fax:773-947-0482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid
IL=========002Medicaid