Provider Demographics
NPI:1558808204
Name:CONVERGENT DIAGNOSTICS, LLC
Entity Type:Organization
Organization Name:CONVERGENT DIAGNOSTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-501-5171
Mailing Address - Street 1:190 E STACY RD
Mailing Address - Street 2:STE 306-198
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75002-8734
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:718 S GREENVILLE AVE STE 100
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75002-3319
Practice Address - Country:US
Practice Address - Phone:214-501-5171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-19
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D2113081291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR258363709Medicaid
UT4023123Medicaid
SCL00798Medicaid
GA003241278AMedicaid
NM11156732Medicaid
TNQ063561Medicaid
PA103832022Medicaid
WA2170959Medicaid
TX391795701Medicaid
CO9000188531Medicaid
AK1718359Medicaid
OR500787275Medicaid
NE10026847100Medicaid
ND1482077Medicaid
OH425279Medicaid
KS201313520AMedicaid
AL264709Medicaid
MO700090968Medicaid
AZ80116Medicaid