Basic Information
| Provider Information | |||||||||
| NPI: | 1023041233 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BLUE ISLAND PATHOLOGY LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 BURR OAK AVE | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | BLUE ISLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604063802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083880423 | ||||||||
| FaxNumber: | 7083881477 | ||||||||
| Practice Location | |||||||||
| Address1: | 12935 GREGORY ST | ||||||||
| Address2: | |||||||||
| City: | BLUE ISLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604062428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085972000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | MANCUSO | ||||||||
| AuthorizedOfficialFirstName: | PATTY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7083880423 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Cytopathology |
ID Information
| ID | Type | State | Issuer | Description | 01619974 | 01 | IL | BCBS OF IL | OTHER |