Provider Demographics
NPI:1669840674
Name:IMMUCOR GTI DIAGNOSTICS, INC.
Entity Type:Organization
Organization Name:IMMUCOR GTI DIAGNOSTICS, INC.
Other - Org Name:IMMUCOR DX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT, CHIEF ADMINISTRATIV
Authorized Official - Prefix:MS
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-225-8501
Mailing Address - Street 1:301 MICHIGAN ST NE STE 574
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-3314
Mailing Address - Country:US
Mailing Address - Phone:616-284-3818
Mailing Address - Fax:616-284-3738
Practice Address - Street 1:301 MICHIGAN ST NE
Practice Address - Street 2:SUITE 580
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3314
Practice Address - Country:US
Practice Address - Phone:616-284-3818
Practice Address - Fax:616-284-3838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-08
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI23D1054909291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA031049OtherSTATE LICENSURE
AZ156426Medicaid
KY7100431260Medicaid
CACOS00800270OtherSTATE LICENSE
MD1571OtherSTATE LICENSE
MI23D1054909OtherCLIA CERTIFICATION
KS201131960AMedicaid
FL800028023OtherSTATE LICENSE
SCL00526Medicaid
RILCO00995OtherSTATE LICENSE
MI1669840674Medicaid
PA031049OtherSTATE LICENSURE