1225175219 NPI number — NEUROLAB NEURODIAGNOSTIC SERVICES, SC

Table of content: (NPI 1225175219)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225175219 NPI number — NEUROLAB NEURODIAGNOSTIC SERVICES, SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEUROLAB NEURODIAGNOSTIC SERVICES, SC
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:
Provider Other Organization Name Type Code:
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:
1225175219
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 178
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIBERTYVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60048-0178
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-477-7678
Provider Business Mailing Address Fax Number:
847-573-1944

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1614 N HARLEM AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELMWOOD PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60707-4302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-477-4678
Provider Business Practice Location Address Fax Number:
847-573-1944
Provider Enumeration Date:
01/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
THURSTON
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
847-477-7678

Provider Taxonomy Codes

  • Taxonomy code: 111NN0400X , with the licence number:  038-005346 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4932633 . This is a "BC/BS OF IL" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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