Provider Demographics
NPI:1750563219
Name:WESTCHESTER DIAGNOSTIC LABORATORY
Entity type:Organization
Organization Name:WESTCHESTER DIAGNOSTIC LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:G
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-492-0502
Mailing Address - Street 1:3183 PAYSPHERE CIR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0031
Mailing Address - Country:US
Mailing Address - Phone:708-492-0502
Mailing Address - Fax:708-492-0565
Practice Address - Street 1:2225 ENTERPRISE DR
Practice Address - Street 2:SUITE 2511
Practice Address - City:WESTCHESTER
Practice Address - State:IL
Practice Address - Zip Code:60154-5814
Practice Address - Country:US
Practice Address - Phone:708-486-0076
Practice Address - Fax:708-486-0080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherEIN
IL216096Medicare PIN