Provider Demographics
NPI:1154317360
Name:EASTRIDGE MEDICAL LABORATORY INC
Entity Type:Organization
Organization Name:EASTRIDGE MEDICAL LABORATORY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-233-9313
Mailing Address - Street 1:PO BOX 8687
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64508-8687
Mailing Address - Country:US
Mailing Address - Phone:816-233-9313
Mailing Address - Fax:816-233-5043
Practice Address - Street 1:212 SOUTH WOODBINE RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506
Practice Address - Country:US
Practice Address - Phone:816-233-9313
Practice Address - Fax:816-233-5043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
26DO652292OtherCLIA
KS7059727201Medicaid
26DO652292OtherCLIA
9001237Medicare ID - Type Unspecified