Provider Demographics
NPI:1942666367
Name:IDTOX PLLC
Entity Type:Organization
Organization Name:IDTOX PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RACHID
Authorized Official - Middle Name:
Authorized Official - Last Name:IDRISSI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-359-8643
Mailing Address - Street 1:104 STATE AVE STE 101-104
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27520-5116
Mailing Address - Country:US
Mailing Address - Phone:919-243-1831
Mailing Address - Fax:919-243-1830
Practice Address - Street 1:104 STATE AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-5116
Practice Address - Country:US
Practice Address - Phone:919-243-1831
Practice Address - Fax:919-243-1830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-14
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC212822291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2328140OtherMEDICARE PROVIDER NUMBER