Provider Demographics
NPI:1568561512
Name:PH ENTERPRISES INC
Entity Type:Organization
Organization Name:PH ENTERPRISES INC
Other - Org Name:MAG LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MT ASCP
Authorized Official - Phone:620-232-1900
Mailing Address - Street 1:200 E CENTENNIAL DR
Mailing Address - Street 2:STE 10A
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762-6571
Mailing Address - Country:US
Mailing Address - Phone:620-232-1900
Mailing Address - Fax:620-232-8752
Practice Address - Street 1:200 E CENTENNIAL DR
Practice Address - Street 2:STE 10A
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-6571
Practice Address - Country:US
Practice Address - Phone:620-232-1900
Practice Address - Fax:620-232-8752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100374300AMedicaid
KS690009001OtherRR MEDICARE
KS117920Medicare ID - Type UnspecifiedBCBS