Provider Demographics
NPI:1255729471
Name:AFFINITY LAB
Entity type:Organization
Organization Name:AFFINITY LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:MRS
Authorized Official - First Name:ABBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-304-7674
Mailing Address - Street 1:29201 TELEGRAPH RD STE 450
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-7604
Mailing Address - Country:US
Mailing Address - Phone:248-304-7659
Mailing Address - Fax:248-423-4683
Practice Address - Street 1:29201 TELEGRAPH RD STE 400
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-7647
Practice Address - Country:US
Practice Address - Phone:248-552-8525
Practice Address - Fax:248-552-1134
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOENIX MEDICAL GROUP, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-12-23
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI23D2080682OtherCLIA