BOSTWICK LABORATORIES, INC.

Provider Demographics

• NPI: 1952465288
• Name: BOSTWICK LABORATORIES, INC.
• Entity Type: Organization
• Organization Name: BOSTWICK LABORATORIES, INC.
• Authorized Official - Title/Position: CEO, PRESIDENT, CHIEF MED. OFFICER
• Authorized Official - Prefix: DR
• Authorized Official - First Name: DAVID
• Authorized Official - Middle Name: GRANGER
• Authorized Official - Last Name: BOSTWICK
• Authorized Official - Credentials: MD
• Authorized Official - Phone: 804-967-9225
• Mailing Address - Street 1: PO BOX 403751
• Mailing Address - City: ATLANTA
• Mailing Address - State: GA
• Mailing Address - Zip Code: 30384-3751
• Mailing Address - Country: US
• Mailing Address - Phone: 804-967-9225
• Mailing Address - Fax: 804-239-1954
• Practice Address - Street 1: 4851 LAKE BROOK DR
• Practice Address - City: GLEN ALLEN
• Practice Address - State: VA
• Practice Address - Zip Code: 23060-9233
• Practice Address - Country: US
• Practice Address - Phone: 804-967-9225
• Practice Address - Fax: 804-239-1954
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-12-21
• Last Update Date: 2012-05-22
• Deactivation Date: 2011-10-06
• Reactivation Date: 2012-02-27

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization
Yes	291U00000X	Laboratories	Clinical Medical Laboratory

Provider Identifiers

State	Identifier ID	ID Type	Issuer
DC	036874800	Medicaid
IA	0578229	Medicaid
NV	100503849	Medicaid
LA	1198722	Medicaid
WY	120124700	Medicaid
MI	164650710	Medicaid
ME	419300000	Medicaid
WV	6701112000	Medicaid
AL	690000006	Medicaid
VA	010062811	Medicaid
OH	2420571	Medicaid
TN	4582490	Medicaid
MT	0421311	Medicaid
KS	200262210A	Medicaid
CO	32287232	Medicaid
MD	409261900	Medicaid
MO	706132305	Medicaid
WA	7123995	Medicaid
ID	8069026	Medicaid
SC	L00184	Medicaid
MS	01837399	Medicaid
WI	32940800	Medicaid
FL	911980900	Medicaid
VA	138056	Other	ANTHEM BCBS OF VIRGINIA
AR	152979709	Medicaid
AZ	533631	Other	MERCY CARE PLAN
GA	568644630A	Medicaid
PA	1009021320002	Medicaid
TX	164040101	Medicaid
VA	190000932	Other	MEDICARE PTAN
SC	20073351	Other	SC SELECT HEALTH /MEDICAID HMO
OR	275326 MCD	Medicaid
AZ	440615	Medicaid
NM	82083339	Medicaid
OH	000000265139	Other	UNISON HEALTH (OH MEDICAID HMO)
DC	036874800	Other	DC MEDICAID (ACS)
RI	1900009	Medicaid
MN	1952465288	Medicaid
OK	200024720A	Medicaid
IN	200375010A	Medicaid
KY	37000718	Medicaid
NC	7001242	Medicaid
ID	8069026	Medicaid
IL	=========001	Medicaid
MN	1952465288	Medicaid
NC	7001242	Medicaid
LA	1198722	Medicaid