1629047436 NPI number — BROOKSIDE CLINICAL LABORATORY INC

Table of content: (NPI 1629047436)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629047436 NPI number — BROOKSIDE CLINICAL LABORATORY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROOKSIDE CLINICAL LABORATORY 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:
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:
1629047436
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/06/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2901 DUTTON MILL RD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ASTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19014-2850
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-872-6466
Provider Business Mailing Address Fax Number:
610-872-7628

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2901 DUTTON MILL RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19014-2850
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-872-6466
Provider Business Practice Location Address Fax Number:
610-872-7628
Provider Enumeration Date:
03/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
IACONO
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER DIRECTOR
Authorized Official Telephone Number:
610-872-6466

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  PA000472 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 398126 . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8034907 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 398126 . This is a "RAILROAD TRAVELERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0007670710001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0000991109 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".




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