Provider Demographics
NPI:1366612731
Name:MODERN LABORATORY INCORPORATED
Entity type:Organization
Organization Name:MODERN LABORATORY INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PRASANTA
Authorized Official - Middle Name:K
Authorized Official - Last Name:GHOSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-933-8101
Mailing Address - Street 1:1793 BLOOMINGDALE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:GLENDALE HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60139-3800
Mailing Address - Country:US
Mailing Address - Phone:630-933-8101
Mailing Address - Fax:630-933-8105
Practice Address - Street 1:1793 BLOOMINGDALE RD STE 1
Practice Address - Street 2:
Practice Address - City:GLENDALE HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60139-3800
Practice Address - Country:US
Practice Address - Phone:630-933-8101
Practice Address - Fax:630-933-8105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL291U00000X291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14D1079331OtherCLIA
IL216691OtherPTAN