Provider Demographics
NPI:1093202137
Name:MDCONNECT HEALTHCARE CORPORATION
Entity Type:Organization
Organization Name:MDCONNECT HEALTHCARE CORPORATION
Other - Org Name:MDCONNECT LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:GREVIOUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-914-8286
Mailing Address - Street 1:11161 E STATE ROAD 70 UNIT 110
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34202-9407
Mailing Address - Country:US
Mailing Address - Phone:800-926-3047
Mailing Address - Fax:941-296-8588
Practice Address - Street 1:1612 DOWNTOWN WEST BLVD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-5408
Practice Address - Country:US
Practice Address - Phone:800-926-3047
Practice Address - Fax:941-296-8588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-14
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
No247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physicianGroup - Single Specialty