Provider Demographics
NPI:1467449124
Name:FORUM HEALTH OUTREACH LABORATORIES, INC.
Entity Type:Organization
Organization Name:FORUM HEALTH OUTREACH LABORATORIES, INC.
Other - Org Name:CLIN LAB
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:SEELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-841-3540
Mailing Address - Street 1:811 SOUTHWESTERN RUN
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44514-3688
Mailing Address - Country:US
Mailing Address - Phone:330-629-8033
Mailing Address - Fax:330-629-9952
Practice Address - Street 1:811 SOUTHWESTERN RUN
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44514-3688
Practice Address - Country:US
Practice Address - Phone:330-629-8033
Practice Address - Fax:330-629-9952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-28
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0578343Medicaid
OH0578343Medicaid