Provider Demographics
NPI:1689879249
Name:A,GENERAL LAB CORP
Entity Type:Organization
Organization Name:A,GENERAL LAB CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SALMA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-595-5100
Mailing Address - Street 1:1793 BLOOMINGDALE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:GLENDALE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60139-3800
Mailing Address - Country:US
Mailing Address - Phone:630-933-9373
Mailing Address - Fax:630-373-4545
Practice Address - Street 1:1793 BLOOMINGDALE RD STE 1
Practice Address - Street 2:
Practice Address - City:GLENDALE HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60139-3800
Practice Address - Country:US
Practice Address - Phone:630-933-9373
Practice Address - Fax:630-373-4545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL364296016001Medicaid