Provider Demographics
NPI:1962674358
Name:MEDTOXDX LLC
Entity Type:Organization
Organization Name:MEDTOXDX LLC
Other - Org Name:MEDTOX DIAGNOSTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LAB MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ERUM
Authorized Official - Middle Name:A
Authorized Official - Last Name:NAQVI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-522-5261
Mailing Address - Street 1:310 CLAY AVE
Mailing Address - Street 2:
Mailing Address - City:JEANNETTE
Mailing Address - State:PA
Mailing Address - Zip Code:15644-2120
Mailing Address - Country:US
Mailing Address - Phone:724-522-5261
Mailing Address - Fax:724-522-5170
Practice Address - Street 1:310 CLAY AVE
Practice Address - Street 2:
Practice Address - City:JEANNETTE
Practice Address - State:PA
Practice Address - Zip Code:15644-2120
Practice Address - Country:US
Practice Address - Phone:724-522-5261
Practice Address - Fax:724-522-5170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA029704291U00000X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1022072100001Medicaid
PA130927Medicare PIN
PA1022072100001Medicaid