Provider Demographics
NPI:1700100211
Name:IMMUNOGEN DIAGNOSTICS, LLC
Entity Type:Organization
Organization Name:IMMUNOGEN DIAGNOSTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:NEEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-808-1429
Mailing Address - Street 1:50 FAIRFIELD RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07004-2414
Mailing Address - Country:US
Mailing Address - Phone:973-808-5550
Mailing Address - Fax:973-808-5999
Practice Address - Street 1:50 FAIRFIELD RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07004-2414
Practice Address - Country:US
Practice Address - Phone:973-808-5550
Practice Address - Fax:973-808-5999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-26
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ31D1107857OtherCLIA