Provider Demographics
NPI:1881630614
Name:QUEST DIAGNOSTICS LLC IL
Entity Type:Organization
Organization Name:QUEST DIAGNOSTICS LLC IL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:BOWLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-454-4122
Mailing Address - Street 1:1201 S COLLEGEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:COLLEGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19426-2998
Mailing Address - Country:US
Mailing Address - Phone:866-697-8378
Mailing Address - Fax:
Practice Address - Street 1:1355 MITTEL BLVD
Practice Address - Street 2:
Practice Address - City:WOOD DALE
Practice Address - State:IL
Practice Address - Zip Code:60191-1024
Practice Address - Country:US
Practice Address - Phone:800-323-5917
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:QUEST DIAGNOSTICS INCORPORATED
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-21
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14D0417052291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL570920Medicare PIN
570920Medicare ID - Type Unspecified