1265620223 NPI number — COMBINED PHYSICIANS LAB LLC

Table of content: (NPI 1265620223)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265620223 NPI number — COMBINED PHYSICIANS LAB LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMBINED PHYSICIANS LAB LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
INTEGRATED DX LLC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265620223
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3945 SIMPSON LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40475-9113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-353-8464
Provider Business Mailing Address Fax Number:
855-704-1599

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3945 SIMPSON LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40475-9113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-353-8464
Provider Business Practice Location Address Fax Number:
855-704-1599
Provider Enumeration Date:
10/04/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BAILEY
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
859-353-8464

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 220001795 . This is a "RRMC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 37901212 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000061984 . This is a "BLUECROSS BLUESHIELD" identifier . This identifiers is of the category "OTHER".