1417250945 NPI number — INTERPACE DIAGNOSTICS LAB, INC.

Table of content: (NPI 1417250945)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417250945 NPI number — INTERPACE DIAGNOSTICS LAB, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERPACE DIAGNOSTICS LAB, 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:
1417250945
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 CHURCH ST S
Provider Second Line Business Mailing Address:
SUITE B-05
Provider Business Mailing Address City Name:
NEW HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06519-1717
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-252-3558
Provider Business Mailing Address Fax Number:
203-624-5742

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 CHURCH ST S
Provider Second Line Business Practice Location Address:
SUITE B-05
Provider Business Practice Location Address City Name:
NEW HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06519-1717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-252-3558
Provider Business Practice Location Address Fax Number:
203-624-5742
Provider Enumeration Date:
12/06/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MIAO
Authorized Official First Name:
GRAHAM
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
862-207-7824

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  CL-0664 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: D300076340 . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 07D1091103 . This is a "CLIA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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