Impala Express Clinical Laboratory Service Inc

Primary specialty

Clinical Medical LaboratoryTaxonomy code 291U00000X

License

14D2018991 Issued in IL

Legal business name

IMPALA EXPRESS CLINICAL LABORATORY SERVICE INC

Practice address

845 N Michigan Ave Ste 944E
845 N. Michigan Ave, Suite # 944-E
Chicago, IL 60611-2213

Phone

(312) 202-0328

Fax

(312) 202-0320

NPI assigned

Apr 12, 2011

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Alemayehu M Gebresellassie

Title

President

Phone

(847) 951-5168

Specialties & licenses 1

Addresses

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Alemayehu (Alex) M Gebresellassie, MLT

  • Medical Laboratory Technician
  • Chicago, IL
  • NPI 1588962609
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1302566400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1339459200000",
    "number": "1346530201",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "845 N MICHIGAN AVE STE 944E",
            "address_2": "845 N. MICHIGAN AVE, SUITE # 944-E",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606112213",
            "telephone_number": "312-202-0328",
            "fax_number": "312-202-0320"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "845 N MICHIGAN AVE STE 944E",
            "address_2": "845 N. MICHIGAN AVE, SUITE # 944-E",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606112213",
            "telephone_number": "312-202-0328",
            "fax_number": "312-202-0320"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IMPALA EXPRESS CLINICAL LABORATORY SERVICE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-04-12",
        "last_updated": "2012-06-12",
        "status": "A",
        "authorized_official_last_name": "GEBRESELLASSIE",
        "authorized_official_first_name": "ALEMAYEHU",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "847-951-5168",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": "IL",
            "license": "14D2018991",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Clinical Medical Laboratory in Chicago, IL
• Providers in Chicago, IL by specialty
• Clinical Medical Laboratory in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 12, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.