Provider Demographics
NPI:1952918831
Name:UNITED MEDICAL LABORATORY LLC
Entity Type:Organization
Organization Name:UNITED MEDICAL LABORATORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TEOFIL
Authorized Official - Middle Name:
Authorized Official - Last Name:GHERASIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-837-0868
Mailing Address - Street 1:4520 FIRESTONE ST STE C
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-4602
Mailing Address - Country:US
Mailing Address - Phone:248-837-0868
Mailing Address - Fax:
Practice Address - Street 1:4520 FIRESTONE ST STE C
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-4602
Practice Address - Country:US
Practice Address - Phone:248-837-0868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-25
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory