Provider Demographics
NPI:1750362224
Name:DOCTOR'S DATA, INC.
Entity type:Organization
Organization Name:DOCTOR'S DATA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:S
Authorized Official - Last Name:HICKOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-377-8139
Mailing Address - Street 1:3755 ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2420
Mailing Address - Country:US
Mailing Address - Phone:630-377-8139
Mailing Address - Fax:630-587-7860
Practice Address - Street 1:3755 ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2420
Practice Address - Country:US
Practice Address - Phone:630-377-8139
Practice Address - Fax:630-587-7860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-10
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL14D0646470291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL148453Medicare ID - Type Unspecified