Provider Demographics
NPI:1629047436
Name:BROOKSIDE CLINICAL LABORATORY INC
Entity Type:Organization
Organization Name:BROOKSIDE CLINICAL LABORATORY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:IACONO
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:610-872-6466
Mailing Address - Street 1:2901 DUTTON MILL RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ASTON
Mailing Address - State:PA
Mailing Address - Zip Code:19014-2850
Mailing Address - Country:US
Mailing Address - Phone:610-872-6466
Mailing Address - Fax:610-872-7628
Practice Address - Street 1:2901 DUTTON MILL RD STE 100
Practice Address - Street 2:
Practice Address - City:ASTON
Practice Address - State:PA
Practice Address - Zip Code:19014-2850
Practice Address - Country:US
Practice Address - Phone:610-872-6466
Practice Address - Fax:610-872-7628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPA000472291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
398126OtherBLUE SHIELD
NJ8034907Medicaid
398126OtherRAILROAD TRAVELERS
PA0007670710001Medicaid
DE0000991109Medicaid
398126OtherRAILROAD TRAVELERS