Provider Demographics
NPI:1205876554
Name:OAK CREST LABORATORY SERVICES, INC
Entity type:Organization
Organization Name:OAK CREST LABORATORY SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:GAMBINO
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:708-567-1231
Mailing Address - Street 1:1452 MERCHANT DR UNIT B
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-5917
Mailing Address - Country:US
Mailing Address - Phone:708-634-6180
Mailing Address - Fax:708-634-6181
Practice Address - Street 1:1452 MERCHANT DR UNIT B
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-5917
Practice Address - Country:US
Practice Address - Phone:708-634-6180
Practice Address - Fax:708-634-6181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14D0418588291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1205876554OtherANTHEM BLUE CROSS PPO
IL1205876554OtherBLUE CROSS BLUE SHIELD
IL=========001Medicaid
IL=========001Medicaid