Basic Information
| Provider Information | |||||||||
| NPI: | 1336205913 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLINIC LABORATORY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2601 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629011031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185495361 | ||||||||
| FaxNumber: | 6185495128 | ||||||||
| Practice Location | |||||||||
| Address1: | 2601 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CARBONDALE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 629011031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185495361 | ||||||||
| FaxNumber: | 6185495128 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2006 | ||||||||
| LastUpdateDate: | 05/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | NORMAN | ||||||||
| AuthorizedOfficialFirstName: | ALLAN | ||||||||
| AuthorizedOfficialMiddleName: | N. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6184575200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CARBONDALE CLINIC, S.C. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 148511 | 01 | IL | LEGACY | OTHER | 690003493 | 01 | IL | RR MEDICARE | OTHER | 196086 | 01 | IL | GHP | OTHER | 044649 | 01 | IL | HAMP | OTHER | 461070 | 01 | IL | HEALTHLINK | OTHER |