Provider Demographics
NPI:1679533210
Name:MID AMERICA CLINICAL LABORATORIES, LLC
Entity Type:Organization
Organization Name:MID AMERICA CLINICAL LABORATORIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:KMETZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-803-1010
Mailing Address - Street 1:2560 N SHADELAND AVE
Mailing Address - Street 2:P.O. BOX 19163
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-1705
Mailing Address - Country:US
Mailing Address - Phone:317-803-1010
Mailing Address - Fax:317-803-0186
Practice Address - Street 1:2001 W 86TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1902
Practice Address - Country:US
Practice Address - Phone:317-803-0405
Practice Address - Fax:317-803-0433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-27
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN15D0931996291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN15D0931996OtherCLIA
IN1680601OtherCAP
IN200191460AMedicaid
IN676420Medicare ID - Type UnspecifiedIDENTIFICATION