1508089418 NPI number — ALPHA CLINICAL LABORATORIES, LLC

Table of content: (NPI 1508089418)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508089418 NPI number — ALPHA CLINICAL LABORATORIES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALPHA CLINICAL LABORATORIES, 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:
1508089418
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9 GWYNNS MILL CT
Provider Second Line Business Mailing Address:
SUITE F
Provider Business Mailing Address City Name:
OWINGS MILLS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21117-3527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-363-4301
Provider Business Mailing Address Fax Number:
410-363-4301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9 GWYNNS MILL CT
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
OWINGS MILLS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21117-3527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-363-4301
Provider Business Practice Location Address Fax Number:
410-363-4301
Provider Enumeration Date:
04/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CHIKVASHVILI
Authorized Official First Name:
RAFAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT-CEO
Authorized Official Telephone Number:
410-363-4301

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  39D2043923 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X , with the licence number: 21D1066645 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 412773100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2819 . This is a "FEDERAL BLUE SHIELD" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".
  • Identifier: 72WHAL . This is a "CAREFIRST" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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