Provider Demographics
NPI:1770722100
Name:CLONGEN LABORATORIES, LLC
Entity type:Organization
Organization Name:CLONGEN LABORATORIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND LABORATORY DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AHMED
Authorized Official - Middle Name:FATHY
Authorized Official - Last Name:KILANI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:301-916-0173
Mailing Address - Street 1:12321 MIDDLEBROOK RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20874-1591
Mailing Address - Country:US
Mailing Address - Phone:301-916-0173
Mailing Address - Fax:301-916-0175
Practice Address - Street 1:12321 MIDDLEBROOK RD
Practice Address - Street 2:SUITE 120
Practice Address - City:GERMANTOWN
Practice Address - State:MD
Practice Address - Zip Code:20874-1591
Practice Address - Country:US
Practice Address - Phone:301-916-0173
Practice Address - Fax:301-916-0175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-09
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1206291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD=========Medicare UPIN