Provider Demographics
NPI:1841280815
Name:PHOENIX MEDICAL LABORATORY
Entity type:Organization
Organization Name:PHOENIX MEDICAL LABORATORY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:P
Authorized Official - Last Name:GASPARINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-768-0600
Mailing Address - Street 1:12701 COMMONWEALTH DR
Mailing Address - Street 2:SUITE 6
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33913-8626
Mailing Address - Country:US
Mailing Address - Phone:239-768-0600
Mailing Address - Fax:239-768-0711
Practice Address - Street 1:12701 COMMONWEALTH DR
Practice Address - Street 2:SUITE 6
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33913-8626
Practice Address - Country:US
Practice Address - Phone:239-768-0600
Practice Address - Fax:239-768-0711
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEOGENOMICS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-21
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8000017185291U00000X
FLCLIA10D1023653291U00000X
FL8000019289291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLL9266OtherBCBS FL
FLE9147Medicare PIN
FLL9266OtherBCBS FL