1407850985 NPI number — SOLSTAS LAB PARTNERS GROUP LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407850985 NPI number — SOLSTAS LAB PARTNERS GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOLSTAS LAB PARTNERS GROUP 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:
Provider Other Organization Name Type Code:
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:
1407850985
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1201 S COLLEGEVILLE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLEGEVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19146-2998
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-454-6147
Provider Business Mailing Address Fax Number:
484-676-5309

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2906 JULIA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VALDOSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31602-1435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-244-4468
Provider Business Practice Location Address Fax Number:
229-249-8191
Provider Enumeration Date:
06/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CONDE
Authorized Official First Name:
WILSON
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
800-227-0446

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  092002 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: L00065 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: L8165 . This is a "BLUE CROSS BLUE SHIELD FL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 00057164A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 52183605 . This is a "BLUE CROSS BLUE SHIELD GA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 600-27858 . This is a "BLUE CROSS BLUE SHIELD AL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 030253800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 065023369 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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