Provider Demographics
NPI:1043366933
Name:INTRACELLULAR DIAGNOSTICS, INC
Entity Type:Organization
Organization Name:INTRACELLULAR DIAGNOSTICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BURTON
Authorized Official - Middle Name:B
Authorized Official - Last Name:SILVER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:541-245-3212
Mailing Address - Street 1:945 TOWN CENTRE DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6190
Mailing Address - Country:US
Mailing Address - Phone:541-245-3212
Mailing Address - Fax:
Practice Address - Street 1:945 TOWN CENTRE DR
Practice Address - Street 2:SUITE A
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6190
Practice Address - Country:US
Practice Address - Phone:541-245-3212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR05D0643971291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORCOS00004338OtherCA OUT OF STATE
CA05D0643971OtherCLIA NUMBER
OR05D0643971OtherCLIA
CACLF 4338OtherLAB ID NUMBER, CALIFORNIA