Provider Demographics
NPI:1194711234
Name:COMPREHENSIVE HEMOSTASIS AND THROMBOSIS INSTITUTE
Entity type:Organization
Organization Name:COMPREHENSIVE HEMOSTASIS AND THROMBOSIS INSTITUTE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-688-1345
Mailing Address - Street 1:4727 N SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5925
Mailing Address - Country:US
Mailing Address - Phone:309-688-1345
Mailing Address - Fax:309-688-0917
Practice Address - Street 1:4727 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5925
Practice Address - Country:US
Practice Address - Phone:309-688-1345
Practice Address - Fax:309-688-0917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-23
Last Update Date:2008-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
14D0982678 CLIA291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00115815OtherRAILROAD MEDICARE
IL7230099OtherBCBS OF IL
P00115815OtherRAILROAD MEDICARE
IL=========001Medicaid