Modern Laboratory Incorporated

Primary specialty

Clinical Medical LaboratoryTaxonomy code 291U00000X

License

291U00000X Issued in IL

Legal business name

MODERN LABORATORY INCORPORATED

Practice address

1793 Bloomingdale Rd Ste 1
Glendale Heights, IL 60139-3800

Phone

(630) 933-8101

Fax

(630) 933-8105

NPI assigned

Mar 3, 2008

Organization subpart

No

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

Authorized official

Name

Mr. Prasanta K Ghose

Title

President

Phone

(630) 933-8101

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

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

{
    "created_epoch": "1204502400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1410998400000",
    "number": "1366612731",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1793 BLOOMINGDALE RD STE 1",
            "city": "GLENDALE HEIGHTS",
            "state": "IL",
            "postal_code": "601393800",
            "telephone_number": "630-933-8101",
            "fax_number": "630-933-8105"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1793 BLOOMINGDALE RD STE 1",
            "city": "GLENDALE HEIGHTS",
            "state": "IL",
            "postal_code": "601393800",
            "telephone_number": "630-933-8101",
            "fax_number": "630-933-8105"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MODERN LABORATORY INCORPORATED",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-03-03",
        "last_updated": "2014-09-18",
        "status": "A",
        "authorized_official_last_name": "GHOSE",
        "authorized_official_first_name": "PRASANTA",
        "authorized_official_middle_name": "K",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "630-933-8101",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": "IL",
            "license": "291U00000X",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CLIA",
            "identifier": "14D1079331",
            "state": "IL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PTAN",
            "identifier": "216691",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Providers in Glendale Heights, 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 Sep 18, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; OIG LEIE.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.