Provider Demographics
NPI:1720298292
Name:STAMP CLINICAL LABORATORY,INC
Entity Type:Organization
Organization Name:STAMP CLINICAL LABORATORY,INC
Other - Org Name:PREMIERE DIAGNOSTICS LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SHOBHA
Authorized Official - Middle Name:
Authorized Official - Last Name:STAMPWALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-939-8700
Mailing Address - Street 1:2567 METROPOLITAN PKWY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-7146
Mailing Address - Country:US
Mailing Address - Phone:586-939-8700
Mailing Address - Fax:586-939-8744
Practice Address - Street 1:2567 METROPOLITAN PKWY
Practice Address - Street 2:SUITE 105
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-7146
Practice Address - Country:US
Practice Address - Phone:586-939-8700
Practice Address - Fax:586-939-8744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2121829Medicaid
MI0E01538OtherBCBS PIN NUMBER
MI0E01523Medicare PIN