Provider Demographics
NPI:1225035132
Name:AFFILIATED LABORATORY, INC.
Entity type:Organization
Organization Name:AFFILIATED LABORATORY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:POMEROY
Authorized Official - Suffix:
Authorized Official - Credentials:MT (ASCP)
Authorized Official - Phone:207-973-6905
Mailing Address - Street 1:417 STATE ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6630
Mailing Address - Country:US
Mailing Address - Phone:207-973-6900
Mailing Address - Fax:
Practice Address - Street 1:417 STATE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6630
Practice Address - Country:US
Practice Address - Phone:207-973-6900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMEDLC006Medicaid
ME=========Medicaid