Provider Demographics
NPI:1184055386
Name:THYROID SPECIALTY LABORATORY INC
Entity type:Organization
Organization Name:THYROID SPECIALTY LABORATORY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BHARTUR
Authorized Official - Middle Name:N
Authorized Official - Last Name:PREMACHANDRA
Authorized Official - Suffix:
Authorized Official - Credentials:DSC PHD FRIC
Authorized Official - Phone:314-845-7345
Mailing Address - Street 1:2900 LEMAY FERRY RD
Mailing Address - Street 2:SUITE 114
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63125-3900
Mailing Address - Country:US
Mailing Address - Phone:314-845-7345
Mailing Address - Fax:314-845-7345
Practice Address - Street 1:2900 LEMAY FERRY RD
Practice Address - Street 2:SUITE 114
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63125-3900
Practice Address - Country:US
Practice Address - Phone:314-845-7345
Practice Address - Fax:314-845-7345
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THYROID SPECIALTY LABORATORY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-13
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO703274407Medicaid
26D0953866OtherCLIA
MO703274407Medicaid