Provider Demographics
NPI:1255473906
Name:MACON CLINICAL LABORATORY, INC.
Entity Type:Organization
Organization Name:MACON CLINICAL LABORATORY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:ROY
Authorized Official - Last Name:STUART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-726-5831
Mailing Address - Street 1:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:MS
Mailing Address - Zip Code:39341-0306
Mailing Address - Country:US
Mailing Address - Phone:662-726-5831
Mailing Address - Fax:662-726-4638
Practice Address - Street 1:602 NJEFFERSON STREET
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MS
Practice Address - Zip Code:39341
Practice Address - Country:US
Practice Address - Phone:662-726-5831
Practice Address - Fax:662-726-4638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00120680Medicaid