Provider Demographics
NPI:1255369906
Name:FIRSTSOURCE LABORATORY SOLUTIONS, INC.
Entity type:Organization
Organization Name:FIRSTSOURCE LABORATORY SOLUTIONS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERELY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRADDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-566-9846
Mailing Address - Street 1:10022 LANTERN RD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-9601
Mailing Address - Country:US
Mailing Address - Phone:317-566-9846
Mailing Address - Fax:317-566-9847
Practice Address - Street 1:10022 LANTERN RD
Practice Address - Street 2:SUITE 600
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-9601
Practice Address - Country:US
Practice Address - Phone:317-566-9846
Practice Address - Fax:317-566-9847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040224A291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000345223OtherBLUE SHIELD PROVIDER #
IN000000345223OtherBLUE SHIELD PROVIDER #
IN226380Medicare ID - Type UnspecifiedMEDICARE #