Provider Demographics
NPI:1023053691
Name:O'HARE CLINICAL LAB SERVICES INC
Entity type:Organization
Organization Name:O'HARE CLINICAL LAB SERVICES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:
Authorized Official - Last Name:SIRAJUDEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-552-1355
Mailing Address - Street 1:1420 RENAISSANCE DR STE 206
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1342
Mailing Address - Country:US
Mailing Address - Phone:800-839-2095
Mailing Address - Fax:800-761-3075
Practice Address - Street 1:4909 W DIVISION ST STE 303
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60651-3161
Practice Address - Country:US
Practice Address - Phone:800-839-2095
Practice Address - Fax:800-761-3075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14D1051792291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09932450OtherB/C B/S IL
ILP00397462OtherR/R MEDICARE
IL=========001Medicaid
IL09932450OtherB/C B/S IL