Provider Demographics
NPI:1346218674
Name:SUBURBAN MEDICAL LABORATORY, INC.
Entity Type:Organization
Organization Name:SUBURBAN MEDICAL LABORATORY, INC.
Other - Org Name:MEDLAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR, BILLING
Authorized Official - Prefix:MS
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMOTHERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-201-1117
Mailing Address - Street 1:3575 FOREST LAKE DR
Mailing Address - Street 2:#500
Mailing Address - City:UNIONTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44685
Mailing Address - Country:US
Mailing Address - Phone:330-628-7500
Mailing Address - Fax:300-628-7599
Practice Address - Street 1:3575 FOREST LAKE DR
Practice Address - Street 2:#500
Practice Address - City:UNIONTOWN
Practice Address - State:OH
Practice Address - Zip Code:44685
Practice Address - Country:US
Practice Address - Phone:330-628-7500
Practice Address - Fax:300-628-7599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-11
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36D0339673291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0288004Medicaid
OH36D0339673OtherCLIA
OH0288004Medicaid
OH36D0339673OtherCLIA
OH3681581Medicare PIN