Provider Demographics
NPI:1508451527
Name:MASONIC MEDICAL RESEARCH LABORATORY
Entity Type:Organization
Organization Name:MASONIC MEDICAL RESEARCH LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BARTKOWIAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-624-7487
Mailing Address - Street 1:2150 BLEECKER ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-1738
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2150 BLEECKER ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-1738
Practice Address - Country:US
Practice Address - Phone:315-735-2217
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory