Provider Demographics
NPI:1366625071
Name:WILLOW STREET MEDICAL LABORATORY LLC
Entity Type:Organization
Organization Name:WILLOW STREET MEDICAL LABORATORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:STRASNICK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD JD
Authorized Official - Phone:781-268-2400
Mailing Address - Street 1:200 MAIN STREET
Mailing Address - Street 2:SUITE 220
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860
Mailing Address - Country:US
Mailing Address - Phone:401-721-0970
Mailing Address - Fax:401-721-9931
Practice Address - Street 1:200 MAIN STREET
Practice Address - Street 2:SUITE 220
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860
Practice Address - Country:US
Practice Address - Phone:401-721-0970
Practice Address - Fax:401-721-9931
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILLOW STREET MEDICAL LABORATORY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-17
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIWS60052Medicaid