1053335729 NPI number — MOLECULAR PATHOLOGY LABORATORY NETWORK INC

Table of content: (NPI 1053335729)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053335729 NPI number — MOLECULAR PATHOLOGY LABORATORY NETWORK INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOLECULAR PATHOLOGY LABORATORY NETWORK 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:
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:
1053335729
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 EAST BROADWAY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARYVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37804-5782
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-380-9746
Provider Business Mailing Address Fax Number:
865-380-9191

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 E BROADWAY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARYVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37804-5782
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-380-9746
Provider Business Practice Location Address Fax Number:
865-273-1129
Provider Enumeration Date:
07/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HUBBARD
Authorized Official First Name:
ROGER
Authorized Official Middle Name:
ALLAN
Authorized Official Title or Position:
OWNER, CEO
Authorized Official Telephone Number:
865-380-9746

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  0000003348 , 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: 4067281 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3404226 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com