1023229713 NPI number — MEDICAL GENETICS LAB

Table of content: (NPI 1023229713)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023229713 NPI number — MEDICAL GENETICS LAB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL GENETICS LAB
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:
6
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:
1023229713
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 699
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNTAIN HOME
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37684-0699
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-433-6039
Provider Business Mailing Address Fax Number:
423-433-6060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BUILDING 178, MAPLE AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNTAIN HOME
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37684
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-439-7320
Provider Business Practice Location Address Fax Number:
423-439-7343
Provider Enumeration Date:
05/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LEWIS
Authorized Official First Name:
RUSSELL
Authorized Official Middle Name:
E
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
423-433-6050

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  2298 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1235200676 . This is a "LAB GROUP NPI" identifier . This identifiers is of the category "OTHER".




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