Provider Demographics
NPI:1467433292
Name:INFORM DIAGNOSTICS, INC
Entity Type:Organization
Organization Name:INFORM DIAGNOSTICS, INC
Other - Org Name:(F/K/A CARIS DIAGNOSTICS, INC.)
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:VICE PRESIDENT & GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:WICKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-477-4402
Mailing Address - Street 1:6655 NORTH MACARTHUR BOULEVARD
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT DEPT
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-2443
Mailing Address - Country:US
Mailing Address - Phone:469-621-6078
Mailing Address - Fax:
Practice Address - Street 1:6655 NORTH MACARTHUR BOULEVARD
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039-2243
Practice Address - Country:US
Practice Address - Phone:800-979-8292
Practice Address - Fax:972-767-0126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCL8480Medicare PIN