Provider Demographics
NPI:1225488794
Name:MIDWEST LABORATORY SERVICES LLC
Entity Type:Organization
Organization Name:MIDWEST LABORATORY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAWED
Authorized Official - Middle Name:H
Authorized Official - Last Name:SIDDIQUI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-285-3044
Mailing Address - Street 1:11115 NEW HALLS FERRY RD STE 206
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-7612
Mailing Address - Country:US
Mailing Address - Phone:314-285-3044
Mailing Address - Fax:314-395-8925
Practice Address - Street 1:11115 NEW HALLS FERRY RD STE 206
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-7612
Practice Address - Country:US
Practice Address - Phone:314-285-3044
Practice Address - Fax:314-395-8925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOLC001485840291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO26D2112849OtherCLIA