Organization
FOX VALLEY LABORATORY PHYSICIANS SC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
GLORIA MA M.D. (PRESIDENT)
(877) 852-4669
Entity
Organization
Contact information
Practice address
934 CENTER ST, ELGIN, IL 60120-2125
(847) 608-9544
Mailing address
PO BOX 5133, CHICAGO, IL 60680-5133
(847) 608-9544
Taxonomy
Speciality
Code
Description
License number
State
207ZP0102X
Anatomic Pathology & Clinical Pathology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
01623852
BLUE CROSS BLUE SHIELD
IL
01
—
CJ5859
RAILROAD MEDICARE
IL
Enumeration date
07/09/2006
Last updated
04/08/2015
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