Provider Demographics
NPI:1154720662
Name:DISCOVER DIAGNOSTIC LABORATORY, LLC
Entity type:Organization
Organization Name:DISCOVER DIAGNOSTIC LABORATORY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:COFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-257-0569
Mailing Address - Street 1:702 S ILLINOIS AVE
Mailing Address - Street 2:SUITE B-104
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-7908
Mailing Address - Country:US
Mailing Address - Phone:855-314-3337
Mailing Address - Fax:888-965-6670
Practice Address - Street 1:702 S ILLINOIS AVE
Practice Address - Street 2:SUITE B-104
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-7908
Practice Address - Country:US
Practice Address - Phone:855-314-3337
Practice Address - Fax:888-965-6670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-20
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
No204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic MedicineGroup - Multi-Specialty
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical NeurophysiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PENDINGMedicare UPIN