Provider Demographics
NPI:1134808033
Name:CENTER FOR MOLECULAR CANCER DIAGNOSTICS, INC
Entity type:Organization
Organization Name:CENTER FOR MOLECULAR CANCER DIAGNOSTICS, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING EMPLOYEE
Authorized Official - Prefix:
Authorized Official - First Name:FONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-895-1776
Mailing Address - Street 1:2100 W ROOSEVELT RD STE B
Mailing Address - Street 2:
Mailing Address - City:BROADVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60155-3869
Mailing Address - Country:US
Mailing Address - Phone:330-405-2623
Mailing Address - Fax:
Practice Address - Street 1:2100 W ROOSEVELT RD STE B
Practice Address - Street 2:
Practice Address - City:BROADVIEW
Practice Address - State:IL
Practice Address - Zip Code:60155-3869
Practice Address - Country:US
Practice Address - Phone:330-405-2623
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-17
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory