1669484473 NPI number — MYRIAD GENETIC LABORATORIES, INC.

Table of content: (NPI 1669484473)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669484473 NPI number — MYRIAD GENETIC LABORATORIES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MYRIAD GENETIC LABORATORIES, 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:
1669484473
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/27/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
320 WAKARA WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84108-1214
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-584-3600
Provider Business Mailing Address Fax Number:
801-883-3472

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
322 N 2200 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84116-2922
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-584-3600
Provider Business Practice Location Address Fax Number:
801-584-3615
Provider Enumeration Date:
08/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HO
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
D
Authorized Official Title or Position:
SR. VP PAYER MARKETS
Authorized Official Telephone Number:
801-584-3600

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  46D0880690 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 706248507 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 56130236 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 82350800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: LB323UT , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010210186 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02668124 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200508920A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 409661400 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 46D2094383 . This is a "CLIA" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 912768 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200062220A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 42122333 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 46D2094383 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001383000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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