Provider Demographics
NPI:1801810452
Name:IMUGEN INC
Entity type:Organization
Organization Name:IMUGEN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:P
Authorized Official - Last Name:BERARDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-246-8436
Mailing Address - Street 1:315 NORWOOD PARK S
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062-4681
Mailing Address - Country:US
Mailing Address - Phone:800-246-8436
Mailing Address - Fax:781-255-9923
Practice Address - Street 1:315 NORWOOD PARK S
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062-4681
Practice Address - Country:US
Practice Address - Phone:800-246-8436
Practice Address - Fax:781-255-9923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2015-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2349291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA228396Medicare ID - Type Unspecified