Provider Demographics
NPI:1649390162
Name:ALLEY MEDICAL CENTER LAB
Entity Type:Organization
Organization Name:ALLEY MEDICAL CENTER LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SHELLENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-759-0351
Mailing Address - Street 1:301 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BERWICK
Mailing Address - State:PA
Mailing Address - Zip Code:18603-3603
Mailing Address - Country:US
Mailing Address - Phone:570-759-0351
Mailing Address - Fax:570-759-1992
Practice Address - Street 1:301 W 3RD ST
Practice Address - Street 2:
Practice Address - City:BERWICK
Practice Address - State:PA
Practice Address - Zip Code:18603-3603
Practice Address - Country:US
Practice Address - Phone:570-759-0351
Practice Address - Fax:570-759-1992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA000420291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007302700003Medicaid