Provider Demographics
NPI:1417231226
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:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:HOSKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:5123-752-7300
Mailing Address - Street 1:6800 VIRGINIA MANOR RD
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-4200
Mailing Address - Country:US
Mailing Address - Phone:216-409-7394
Mailing Address - Fax:
Practice Address - Street 1:6800 VIRGINIA MANOR RD
Practice Address - Street 2:
Practice Address - City:BELTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20705-4200
Practice Address - Country:US
Practice Address - Phone:216-409-7394
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-29
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36D0339673291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH36D0339673OtherCLIA
OH00OtherWORKERS COMP
OH0288004Medicaid
OH36D0339673OtherCLIA
OHSU3681581Medicare UPIN