Provider Demographics
NPI:1831343383
Name:GENETIC DIAGNOSTIC LABORATORY
Entity type:Organization
Organization Name:GENETIC DIAGNOSTIC LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ARUPA
Authorized Official - Middle Name:
Authorized Official - Last Name:GANGULY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:215-898-3122
Mailing Address - Street 1:415 CURIE BOULEVARD
Mailing Address - Street 2:415 ANATOMY-CHEMISTRY BUILDING-DEPARTMENT OF GENETICS
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:215-573-9161
Mailing Address - Fax:215-573-5940
Practice Address - Street 1:3620 HAMILTON WALK
Practice Address - Street 2:415 ANATOMY-CHEMSTRY BUILDING
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4215
Practice Address - Country:US
Practice Address - Phone:215-573-9161
Practice Address - Fax:215-573-5940
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-11
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA39D0893887291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory