Provider Demographics
NPI:1417330465
Name:EGL GENETIC DIAGNOSTICS, LLC
Entity Type:Organization
Organization Name:EGL GENETIC DIAGNOSTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:URBANEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-554-5111
Mailing Address - Street 1:2460 MOUNTAIN INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-3812
Mailing Address - Country:US
Mailing Address - Phone:816-251-0440
Mailing Address - Fax:816-347-0143
Practice Address - Street 1:2460 MOUNTAIN INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-3812
Practice Address - Country:US
Practice Address - Phone:470-378-2200
Practice Address - Fax:470-378-2250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-08
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003171558AMedicaid