Provider Demographics
NPI:1760414221
Name:MEDICAL ASSAY LABORATORY
Entity Type:Organization
Organization Name:MEDICAL ASSAY LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTAPHER
Authorized Official - Middle Name:I
Authorized Official - Last Name:CHALOKWU
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:630-515-0418
Mailing Address - Street 1:6006 S CASS AVE STE A
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-2780
Mailing Address - Country:US
Mailing Address - Phone:630-515-0418
Mailing Address - Fax:630-515-0417
Practice Address - Street 1:6006 S CASS AVE STE A
Practice Address - Street 2:
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-2780
Practice Address - Country:US
Practice Address - Phone:630-515-0418
Practice Address - Fax:630-515-0417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2010-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14D1044662291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200812370AMedicaid
IL02232809OtherBLUE SHIELD PROVIDER NUMB
IL=========OtherTAX ID NUMBER
IL=========001Medicaid
IL02232809OtherBLUE SHIELD PROVIDER NUMB
IL=========001Medicaid