Provider Demographics
NPI:1093870255
Name:SKIPPACK CLINICAL LAB
Entity Type:Organization
Organization Name:SKIPPACK CLINICAL LAB
Other - Org Name:SKIPPACK MEDICAL LABORATORY
Other - Org Type:Other Name
Authorized Official - Title/Position:LAB SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:HASU
Authorized Official - Middle Name:B
Authorized Official - Last Name:AMIN
Authorized Official - Suffix:
Authorized Official - Credentials:MS ASCP
Authorized Official - Phone:610-584-1669
Mailing Address - Street 1:PO BOX 817
Mailing Address - Street 2:3887 SKIPPACK PIKE
Mailing Address - City:SKIPPACK
Mailing Address - State:PA
Mailing Address - Zip Code:19474-0817
Mailing Address - Country:US
Mailing Address - Phone:610-584-1669
Mailing Address - Fax:610-584-5188
Practice Address - Street 1:3887 SKIPPACK PIKE
Practice Address - Street 2:
Practice Address - City:SKIPPACK
Practice Address - State:PA
Practice Address - Zip Code:19474-0817
Practice Address - Country:US
Practice Address - Phone:610-584-1669
Practice Address - Fax:610-584-5188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA000421291U00000X
PASK301440291U00000X
PA000983405291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000983405Medicaid
PA000421OtherMEDICARE BLUE SHIELD
PASK301440Medicare ID - Type Unspecified