Provider Demographics
NPI:1336598325
Name:PERSONALIZED GENETICS LLC
Entity Type:Organization
Organization Name:PERSONALIZED GENETICS LLC
Other - Org Name:PERSONALIZED GENOMICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAVITEJ
Authorized Official - Middle Name:B
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-656-4941
Mailing Address - Street 1:607 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15232-1700
Mailing Address - Country:US
Mailing Address - Phone:412-361-6160
Mailing Address - Fax:
Practice Address - Street 1:607 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15232-1700
Practice Address - Country:US
Practice Address - Phone:412-361-6160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-09
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA39D2109711291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1032451710001Medicaid