Basic Information
| Provider Information | |||||||||
| NPI: | 1184777823 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JUSTICE MED-LAB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9050 W 81ST ST | ||||||||
| Address2: | |||||||||
| City: | JUSTICE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604581350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085943500 | ||||||||
| FaxNumber: | 7085630916 | ||||||||
| Practice Location | |||||||||
| Address1: | 9050 W 81ST ST | ||||||||
| Address2: | |||||||||
| City: | JUSTICE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604581350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085943500 | ||||||||
| FaxNumber: | 7085630916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 09/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | CHRISTOU | ||||||||
| AuthorizedOfficialFirstName: | THEODORE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7085630330 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 01629954 | 01 | IL | BCBS | OTHER |