Provider Demographics
NPI:1164962882
Name:IPSUM DIAGNOSTICS LLC
Entity Type:Organization
Organization Name:IPSUM DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:COLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-441-8180
Mailing Address - Street 1:8607 ROBERTS DR STE 250
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30350-2237
Mailing Address - Country:US
Mailing Address - Phone:678-915-2299
Mailing Address - Fax:833-964-0184
Practice Address - Street 1:8607 ROBERTS DR STE 250
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30350-2237
Practice Address - Country:US
Practice Address - Phone:678-915-2299
Practice Address - Fax:833-964-0184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-28
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11D2125186291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX397268901Medicaid
GA060-403OtherGA LICENSE
TX45D2299234OtherCLIA NUMBER
GA003198560AMedicaid