1497199350 NPI number — PHYSICIAN DIAGNOSTIC AND PATHOLOGY

Table of content: (NPI 1497199350)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497199350 NPI number — PHYSICIAN DIAGNOSTIC AND PATHOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIAN DIAGNOSTIC AND PATHOLOGY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ASSOCIATED UROLOGICAL SPEC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497199350
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10400 SOUTHWEST HWY
Provider Second Line Business Mailing Address:
LOWER LEVEL
Provider Business Mailing Address City Name:
CHICAGO RIDGE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60415-1367
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-590-8770
Provider Business Mailing Address Fax Number:
708-428-4277

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7530 W COLLEGE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALOS HEIGHTS
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60463-1196
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-361-8162
Provider Business Practice Location Address Fax Number:
708-361-8173
Provider Enumeration Date:
04/23/2013

Additional Information

Authorized Official

Authorized Official Last Name:
FIRLIT
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
708-361-0840

Provider Taxonomy Codes

  • Taxonomy code: 207ZC0006X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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