Provider Demographics
NPI:1245498104
Name:TAYLORVILLE MEDICAL ASSOCIATES LAB
Entity type:Organization
Organization Name:TAYLORVILLE MEDICAL ASSOCIATES LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRYANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-528-7541
Mailing Address - Street 1:303 E BIDWELL ST
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-1363
Mailing Address - Country:US
Mailing Address - Phone:217-824-4939
Mailing Address - Fax:
Practice Address - Street 1:303 E BIDWELL ST
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568-1363
Practice Address - Country:US
Practice Address - Phone:217-824-4939
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPRINGFIELD CLINIC LLP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-28
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
14D0435310OtherCLIA
14D0435310OtherCLIA