Provider Demographics
NPI:1164795423
Name:BRLI GENPATH DIAGNOSTICS, INC
Entity Type:Organization
Organization Name:BRLI GENPATH DIAGNOSTICS, INC
Other - Org Name:GENPATH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:S
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-791-2600
Mailing Address - Street 1:481 EDWARD H ROSS DR
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07407-3118
Mailing Address - Country:US
Mailing Address - Phone:800-229-5227
Mailing Address - Fax:201-791-1941
Practice Address - Street 1:22610 GATEWAY CENTER DR
Practice Address - Street 2:STE. 100
Practice Address - City:CLARKSBURG
Practice Address - State:MD
Practice Address - Zip Code:20871-2006
Practice Address - Country:US
Practice Address - Phone:800-229-5227
Practice Address - Fax:201-791-1941
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BIO REFERENCE LABORATORIES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-02-17
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDF00034Medicare PIN