Provider Demographics
NPI:1508089418
Name:ALPHA CLINICAL LABORATORIES, LLC
Entity Type:Organization
Organization Name:ALPHA CLINICAL LABORATORIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT-CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CHIKVASHVILI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:410-363-4301
Mailing Address - Street 1:9 GWYNNS MILL CT
Mailing Address - Street 2:SUITE F
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-3527
Mailing Address - Country:US
Mailing Address - Phone:410-363-4301
Mailing Address - Fax:410-363-4301
Practice Address - Street 1:9 GWYNNS MILL CT
Practice Address - Street 2:SUITE F
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-3527
Practice Address - Country:US
Practice Address - Phone:410-363-4301
Practice Address - Fax:410-363-4301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21D1066645291U00000X
PA39D2043923291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD412773100Medicaid
MD2819OtherFEDERAL BLUE SHIELD
MD72WHALOtherCAREFIRST
DCF00044Medicare PIN
MD2819OtherFEDERAL BLUE SHIELD