Provider Demographics
NPI:1003813189
Name:DEJOHN MEDICAL LABORATORIES, INC
Entity Type:Organization
Organization Name:DEJOHN MEDICAL LABORATORIES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:DEJOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-626-2112
Mailing Address - Street 1:1570 GARRETT RD
Mailing Address - Street 2:
Mailing Address - City:UPPER DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19082-4500
Mailing Address - Country:US
Mailing Address - Phone:610-626-2112
Mailing Address - Fax:610-626-5923
Practice Address - Street 1:1570 GARRETT RD
Practice Address - Street 2:
Practice Address - City:UPPER DARBY
Practice Address - State:PA
Practice Address - Zip Code:19082-4500
Practice Address - Country:US
Practice Address - Phone:610-626-2112
Practice Address - Fax:610-626-5923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA000363291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007131880001Medicaid
PA398265Medicare ID - Type UnspecifiedPROVIDER NUMBER