Provider Demographics
NPI:1366484545
Name:PA LABS, LLC
Entity Type:Organization
Organization Name:PA LABS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-284-7795
Mailing Address - Street 1:1200 W WHITE RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-4988
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:765-741-5608
Practice Address - Street 1:2401 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3428
Practice Address - Country:US
Practice Address - Phone:765-284-7795
Practice Address - Fax:765-741-5608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1686OtherPHYSICIAN HEALTH PLAN
OH2099563Medicaid
IN000000012322OtherM PLAN
IN000000255389OtherANTHEM BC/BS
OH2099563Medicaid
IN000000255389OtherANTHEM BC/BS