Provider Demographics
NPI:1881975266
Name:PHC OF BUFFALO GROVE DIAGNOSTIC SERVICES
Entity type:Organization
Organization Name:PHC OF BUFFALO GROVE DIAGNOSTIC SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:A
Authorized Official - Last Name:MAGGIORE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:847-868-3435
Mailing Address - Street 1:150 W HALF DAY RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-6591
Mailing Address - Country:US
Mailing Address - Phone:847-868-3435
Mailing Address - Fax:847-859-5885
Practice Address - Street 1:150 W HALF DAY RD
Practice Address - Street 2:SUITE 105
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-6591
Practice Address - Country:US
Practice Address - Phone:847-868-3435
Practice Address - Fax:847-859-5885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-30
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes293D00000XLaboratoriesPhysiological Laboratory
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Single Specialty