Provider Demographics
NPI:1952942039
Name:ASE MEDICAL INSTITUTE
Entity type:Organization
Organization Name:ASE MEDICAL INSTITUTE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER / CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:M.
Authorized Official - Middle Name:MANDELA
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD(C), CLS(AAB)
Authorized Official - Phone:877-404-0704
Mailing Address - Street 1:344 VICTORY DR
Mailing Address - Street 2:
Mailing Address - City:PARK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60466-2003
Mailing Address - Country:US
Mailing Address - Phone:877-404-0704
Mailing Address - Fax:877-505-2724
Practice Address - Street 1:344 VICTORY DR
Practice Address - Street 2:
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-2003
Practice Address - Country:US
Practice Address - Phone:708-490-3340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-30
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty