1467442152 NPI number — STAT LAB, LLC

Table of content: (NPI 1467442152)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467442152 NPI number — STAT LAB, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STAT 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:
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:
1467442152
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2201 W SUDBURY DR
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47403-3737
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-332-8101
Provider Business Mailing Address Fax Number:
812-332-0435

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2201 W SUDBURY AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47403-3737
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-332-8101
Provider Business Practice Location Address Fax Number:
812-332-0435
Provider Enumeration Date:
10/25/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GEBELE
Authorized Official First Name:
GENE
Authorized Official Middle Name:
P
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
812-332-8101

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  15D0360697 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100283160A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 256020 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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