Provider Demographics
NPI:1063840429
Name:PHYSICIAN LABORATORY CONSULTANTS LLC
Entity Type:Organization
Organization Name:PHYSICIAN LABORATORY CONSULTANTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-228-6496
Mailing Address - Street 1:PO BOX 78545
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63178-8545
Mailing Address - Country:US
Mailing Address - Phone:800-899-5757
Mailing Address - Fax:
Practice Address - Street 1:130 N BROAD ST
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-8132
Practice Address - Country:US
Practice Address - Phone:800-899-5757
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PATHOLOGY ASSOCIATES, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-23
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300030489AMedicaid
GA300030489AMedicaid