Provider Demographics
NPI:1376733584
Name:PHILLIP J STATES LAB
Entity type:Organization
Organization Name:PHILLIP J STATES LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:J
Authorized Official - Last Name:STATES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-938-3550
Mailing Address - Street 1:1464 N MAIN ST STE 5
Mailing Address - Street 2:
Mailing Address - City:PUNXSUTAWNEY
Mailing Address - State:PA
Mailing Address - Zip Code:15767-2609
Mailing Address - Country:US
Mailing Address - Phone:814-938-3550
Mailing Address - Fax:814-938-3679
Practice Address - Street 1:1464 N MAIN ST STE 5
Practice Address - Street 2:
Practice Address - City:PUNXSUTAWNEY
Practice Address - State:PA
Practice Address - Zip Code:15767-2609
Practice Address - Country:US
Practice Address - Phone:814-938-3550
Practice Address - Fax:814-938-3679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD423371291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1019257860001Medicaid
PA1019257860001Medicaid