Provider Demographics
NPI:1396761680
Name:FAULKNER MEDICAL LABORATORIES, INC.
Entity type:Organization
Organization Name:FAULKNER MEDICAL LABORATORIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DISOUNGH
Authorized Official - Middle Name:
Authorized Official - Last Name:TIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-322-8502
Mailing Address - Street 1:410 FERRY ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-7809
Mailing Address - Country:US
Mailing Address - Phone:781-322-8502
Mailing Address - Fax:781-322-8032
Practice Address - Street 1:410 FERRY ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-7809
Practice Address - Country:US
Practice Address - Phone:781-322-8502
Practice Address - Fax:781-322-8032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2432291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA228021OtherBLUE CROSS & BLUE SHIELD
MA801323OtherSECURE HORIZONS
MA0800368Medicaid
MA801323OtherTUFTS HEALTH PLAN
MA00000021296OtherBMC HEALTH NET
MA=========OtherHARVARD PILGRIM
MA801323OtherSECURE HORIZONS