1447506787 NPI number — SUBURBAN MEDICAL LABORATORY, INC.

Table of content: (NPI 1447506787)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447506787 NPI number — SUBURBAN MEDICAL LABORATORY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUBURBAN MEDICAL LABORATORY, INC.
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:
MEDLAB
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:
1447506787
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
665 OHIO PIKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45245-2117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-752-7300
Provider Business Mailing Address Fax Number:
513-201-0013

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
39303 COUNTRY CLUB DR
Provider Second Line Business Practice Location Address:
SUITE C-30
Provider Business Practice Location Address City Name:
FARMINGTON HILLS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48331-3478
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-752-7300
Provider Business Practice Location Address Fax Number:
513-201-0013
Provider Enumeration Date:
07/24/2012

Additional Information

Authorized Official

Authorized Official Last Name:
HOSKINS
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
ELMER
Authorized Official Title or Position:
DIRECTOR, BILLING OPERATIONS
Authorized Official Telephone Number:
513-752-7300

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  36D0339673 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0288004 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 36D0339673 . This is a "CLIA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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