Provider Demographics
NPI:1295496578
Name:ROBERTS, CARYSIA (LAB DIRECTOR)
Entity type:Individual
Prefix:
First Name:CARYSIA
Middle Name:
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LAB DIRECTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 MARYLAND ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46402-2545
Mailing Address - Country:US
Mailing Address - Phone:219-248-4912
Mailing Address - Fax:
Practice Address - Street 1:720 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46402-1808
Practice Address - Country:US
Practice Address - Phone:219-248-4912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-07
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1984OtherGOVERMENT
IN1984Medicaid
IN1984OtherGOVERMENT
IL1984Medicaid