Provider Demographics
NPI:1710696398
Name:MIDWAY SPECIALTY DIAGNOSTICS LLC
Entity Type:Organization
Organization Name:MIDWAY SPECIALTY DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANAND
Authorized Official - Middle Name:
Authorized Official - Last Name:SUKHRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-464-9746
Mailing Address - Street 1:356 E MIDWAY RD
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-7148
Mailing Address - Country:US
Mailing Address - Phone:772-464-9746
Mailing Address - Fax:
Practice Address - Street 1:3255 S US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-6381
Practice Address - Country:US
Practice Address - Phone:772-464-9746
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDWAY SPECIALTY CARE CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-11-22
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory