Provider Demographics
NPI:1790829117
Name:SOUTHERN IILINOIS PATHOLOGY LABORATORY LTD
Entity Type:Organization
Organization Name:SOUTHERN IILINOIS PATHOLOGY LABORATORY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ORDIE
Authorized Official - Middle Name:H
Authorized Official - Last Name:KING
Authorized Official - Suffix:JR
Authorized Official - Credentials:D D S PH D
Authorized Official - Phone:618-466-3645
Mailing Address - Street 1:PO BOX 1166
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-1166
Mailing Address - Country:US
Mailing Address - Phone:618-466-3645
Mailing Address - Fax:618-466-3410
Practice Address - Street 1:6111 VOLLMER LN
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-1062
Practice Address - Country:US
Practice Address - Phone:618-466-3645
Practice Address - Fax:618-466-3410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-18
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL309610Medicare PIN