14D2271251 CLIA NUMBER - PREMIER SUBURBAN MEDICAL GROUP - LOCKPORT

Laboratory Demographics

CLIA Number: 14D2271251

Facility Name: PREMIER SUBURBAN MEDICAL GROUP - LOCKPORT

Facility Address:
16622 W 159TH ST - STE 501
LOCKPORT, IL
ZIP 60441
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Facility Phone Number: 815 300-7764

Facility Type: Physician Office

Certificate Type: Waiver

NPI Number: 1376270843

Taxonomy: 332900000X - Non-Pharmacy Dispensing Site
A site other than a pharmacy that dispenses medicinal preparations under the supervision of a physician to patients for self-administration. (e.g. physician offices, ER, Urgent Care Centers, Rural Health Facilities, etc.)

CLIA Record

Field Name	Field Value
CLIA Number	14D2271251
LAB Type	Physician Office
Facility Name	PREMIER SUBURBAN MEDICAL GROUP - LOCKPORT
Street	16622 W 159TH ST - STE 501
City	LOCKPORT
State	IL
ZIP	60441
Phone	815 300-7764
CertificateType	4
CertificateEffectiveDate	10/31/2022
CertificateExpirationDate	10/30/2024
FacilityType	Waiver

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This page was last updated on: 4/23/2024