Provider Demographics
NPI:1720403116
Name:MYGENOMICS, LLC
Entity Type:Organization
Organization Name:MYGENOMICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHOEB
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMAD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:855-647-4363
Mailing Address - Street 1:11535 PARK WOODS CIR
Mailing Address - Street 2:SUITE E
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-4490
Mailing Address - Country:US
Mailing Address - Phone:855-647-4363
Mailing Address - Fax:
Practice Address - Street 1:11535 PARK WOODS CIR
Practice Address - Street 2:SUITE E
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-4490
Practice Address - Country:US
Practice Address - Phone:855-647-4363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-21
Last Update Date:2024-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207ZP0007X
GA291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No207ZP0007XAllopathic & Osteopathic PhysiciansPathologyMolecular Genetic PathologyGroup - Multi-Specialty