Provider Demographics
NPI:1679584361
Name:PARK MADISON PROFESSIONAL LABORATORIES, INC.
Entity Type:Organization
Organization Name:PARK MADISON PROFESSIONAL LABORATORIES, INC.
Other - Org Name:PARK MADISON LABORATORIES, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:DRESSLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-628-7900
Mailing Address - Street 1:97 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-9002
Mailing Address - Country:US
Mailing Address - Phone:212-628-7900
Mailing Address - Fax:212-628-7950
Practice Address - Street 1:97 E 4TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-9002
Practice Address - Country:US
Practice Address - Phone:212-628-7900
Practice Address - Fax:212-628-7950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33D0130762291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY33D0130762OtherCLIA CERTIFICATE
NY02087061Medicaid
NY00298384Medicaid
NY01469429Medicaid
NY02166892Medicaid
NY00298384Medicaid