Provider Demographics
NPI:1972513661
Name:EVERGREEN SHERIDAN LABORATORIES LTD
Entity type:Organization
Organization Name:EVERGREEN SHERIDAN LABORATORIES LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:A
Authorized Official - Last Name:JUTZI
Authorized Official - Suffix:
Authorized Official - Credentials:LAB TECHNOLOGIST
Authorized Official - Phone:708-423-2660
Mailing Address - Street 1:9760 S KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805
Mailing Address - Country:US
Mailing Address - Phone:708-423-2660
Mailing Address - Fax:708-423-1960
Practice Address - Street 1:9760 S KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805
Practice Address - Country:US
Practice Address - Phone:708-423-2660
Practice Address - Fax:708-423-1960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL50000044OtherBLUE CROSS BLUE SHIELD
IL148103Medicare PIN