Provider Demographics
NPI:1336205913
Name:CLINIC LABORATORY
Entity Type:Organization
Organization Name:CLINIC LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:NORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-457-5200
Mailing Address - Street 1:2601 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1031
Mailing Address - Country:US
Mailing Address - Phone:618-549-5361
Mailing Address - Fax:618-549-5128
Practice Address - Street 1:2601 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1031
Practice Address - Country:US
Practice Address - Phone:618-549-5361
Practice Address - Fax:618-549-5128
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARBONDALE CLINIC, S.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-28
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL148511OtherLEGACY
IL690003493OtherRR MEDICARE
IL196086OtherGHP
IL044649OtherHAMP
IL461070OtherHEALTHLINK
IL=========009Medicaid
IL148511OtherLEGACY
IL148511Medicare PIN