Provider Demographics
NPI:1104802529
Name:MEDFORD MEDICAL LABORATORY INC.
Entity type:Organization
Organization Name:MEDFORD MEDICAL LABORATORY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAPPER
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:781-395-0518
Mailing Address - Street 1:0 GOVERNORS AVE
Mailing Address - Street 2:B-2
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3025
Mailing Address - Country:US
Mailing Address - Phone:781-395-0518
Mailing Address - Fax:781-391-0040
Practice Address - Street 1:0 GOVERNORS AVE
Practice Address - Street 2:B-2
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3025
Practice Address - Country:US
Practice Address - Phone:781-395-0518
Practice Address - Fax:781-391-0040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2191291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0800473Medicaid
MA0800473Medicaid