Provider Demographics
NPI:1669476032
Name:MEDICAL LABORATORY DIAGNOSTICS, INC.
Entity Type:Organization
Organization Name:MEDICAL LABORATORY DIAGNOSTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:N
Authorized Official - Last Name:MITITLENES
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, HCLD
Authorized Official - Phone:973-731-2900
Mailing Address - Street 1:85 HORSEHILL RD
Mailing Address - Street 2:ATTN BILLING DEPT
Mailing Address - City:CEDAR KNOLLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07927-2003
Mailing Address - Country:US
Mailing Address - Phone:973-731-2900
Mailing Address - Fax:973-292-9461
Practice Address - Street 1:85 HORSEHILL RD
Practice Address - Street 2:ATTN BILLING DEPT
Practice Address - City:CEDAR KNOLLS
Practice Address - State:NJ
Practice Address - Zip Code:07927-2003
Practice Address - Country:US
Practice Address - Phone:973-731-2900
Practice Address - Fax:973-292-9461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-13
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0000878291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJNJ0947OtherHEALTHNET PROVIDER #
NJLAB 521OtherOXFORD PROVIDER #
NJ304514OtherMEDICARE PTAN #
NJ690927005OtherPALMETTO GBA RAILROAD M/E
NJ2568802Medicaid
NJLAB 521OtherOXFORD PROVIDER #
NJNJ0947OtherHEALTHNET PROVIDER #