Provider Demographics
NPI:1740237304
Name:WILLOW STREET MEDICAL LAB LLC
Entity Type:Organization
Organization Name:WILLOW STREET MEDICAL LAB LLC
Other - Org Name:WILLOW LABORATORIES AND MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:B
Authorized Official - Last Name:MARCUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-268-2400
Mailing Address - Street 1:280 UNION ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01901-1353
Mailing Address - Country:US
Mailing Address - Phone:781-268-2400
Mailing Address - Fax:
Practice Address - Street 1:280 UNION ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1353
Practice Address - Country:US
Practice Address - Phone:781-593-3480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2346291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0805807Medicaid
TR0059Medicare UPIN