Provider Demographics
NPI:1518983642
Name:BUREAU OF PUBLIC HEALTH LABORATORIES
Entity Type:Organization
Organization Name:BUREAU OF PUBLIC HEALTH LABORATORIES
Other - Org Name:BUREAU OF PUBLIC HEALTH LABORATORIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:JACKSONVILLE LAB DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSANNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:CROWE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-791-1550
Mailing Address - Street 1:1217 N PEARL ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32202-3926
Mailing Address - Country:US
Mailing Address - Phone:904-791-1690
Mailing Address - Fax:904-791-1690
Practice Address - Street 1:1217 PEARL ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32202-3926
Practice Address - Country:US
Practice Address - Phone:904-791-1690
Practice Address - Fax:904-791-1690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL800000296291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL030280500Medicaid
FL030280500Medicaid