Provider Demographics
NPI:1316084015
Name:MEDICAL GENETICS LAB
Entity type:Organization
Organization Name:MEDICAL GENETICS LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR BUSINESS SERVICES
Authorized Official - Prefix:MISS
Authorized Official - First Name:SARA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:STUBBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-984-1925
Mailing Address - Street 1:2500 N STATE ST DEPT CGEN
Mailing Address - Street 2:ROOM R622
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-1925
Mailing Address - Fax:601-984-1916
Practice Address - Street 1:2500 N STATE ST DEPT CGEN
Practice Address - Street 2:ROOM R622
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-1925
Practice Address - Fax:601-984-1916
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEPARTMENT OF PREVENTIVE MEDICINE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-31
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00016106Medicaid