Basic Information
| Provider Information | |||||||||
| NPI: | 1356061477 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARIN MEDICAL LABORATORIES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1615 HILL RD STE B | ||||||||
| Address2: | |||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949474338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152096983 | ||||||||
| FaxNumber: | 4158980870 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 HARRISON AVE | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955013215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074458121 | ||||||||
| FaxNumber: | 4158980870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2022 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
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| AuthorizedOfficialLastName: | PRASAD | ||||||||
| AuthorizedOfficialFirstName: | KEDAR | ||||||||
| AuthorizedOfficialMiddleName: | CHE | ||||||||
| AuthorizedOfficialTitleorPosition: | PATHOLOGIST/PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 4159257174 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MARIN MEDICAL LABORATORIES | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.