Provider Demographics
NPI:1811179104
Name:GREENWOOD MEDICAL LABORATORY, INC
Entity type:Organization
Organization Name:GREENWOOD MEDICAL LABORATORY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:J.
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-881-4163
Mailing Address - Street 1:622 N MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-4082
Mailing Address - Country:US
Mailing Address - Phone:317-881-4163
Mailing Address - Fax:317-885-6194
Practice Address - Street 1:622 N MADISON AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-4082
Practice Address - Country:US
Practice Address - Phone:317-881-4163
Practice Address - Fax:317-885-6194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN251170Medicare PIN