Provider Demographics
NPI:1336468784
Name:SOUTHERN DIAGNOSTIC LABORATORIES, LLC
Entity Type:Organization
Organization Name:SOUTHERN DIAGNOSTIC LABORATORIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOYD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-313-1240
Mailing Address - Street 1:2732 7TH AVE S
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35233-3406
Mailing Address - Country:US
Mailing Address - Phone:205-313-1240
Mailing Address - Fax:205-313-1250
Practice Address - Street 1:1050 RIVER OAKS DRIVE
Practice Address - Street 2:SUITE 120
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39292
Practice Address - Country:US
Practice Address - Phone:601-933-8600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-25
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS25D2003695291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07921751Medicaid
MS07921751Medicaid
AL051554061Medicare PIN