Provider Demographics
NPI:1124137179
Name:DMC CLINICAL LAB INC
Entity type:Organization
Organization Name:DMC CLINICAL LAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:ASFAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-871-1200
Mailing Address - Street 1:2888 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2612
Mailing Address - Country:US
Mailing Address - Phone:313-871-1200
Mailing Address - Fax:313-871-1212
Practice Address - Street 1:2888 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2612
Practice Address - Country:US
Practice Address - Phone:313-871-1200
Practice Address - Fax:313-871-1212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI039079291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2098417Medicaid
MI2098417Medicaid
MI2098417Medicaid
MI0H21636Medicare ID - Type Unspecified