Provider Demographics
NPI:1083957773
Name:SAM'S MEDICAL LABORATORY LLC
Entity Type:Organization
Organization Name:SAM'S MEDICAL LABORATORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:301-828-6854
Mailing Address - Street 1:19614 CLUB HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY VILLAGE
Mailing Address - State:MD
Mailing Address - Zip Code:20886-3035
Mailing Address - Country:US
Mailing Address - Phone:301-963-0519
Mailing Address - Fax:301-963-0513
Practice Address - Street 1:19614 CLUB HOUSE RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY VILLAGE
Practice Address - State:MD
Practice Address - Zip Code:20886-3035
Practice Address - Country:US
Practice Address - Phone:301-963-0519
Practice Address - Fax:301-963-0513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-01
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1790291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory