Provider Demographics
NPI:1396175196
Name:THYROID SPECIALTY LABORATORY INC
Entity type:Organization
Organization Name:THYROID SPECIALTY LABORATORY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF COMPLIANCE & CREDENTIAL
Authorized Official - Prefix:
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ECKRICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-200-3040
Mailing Address - Street 1:1636 HEADLAND DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-2837
Mailing Address - Country:US
Mailing Address - Phone:314-200-2040
Mailing Address - Fax:314-200-3042
Practice Address - Street 1:1636 HEADLAND DR
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2837
Practice Address - Country:US
Practice Address - Phone:314-200-3040
Practice Address - Fax:314-200-3042
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THYROID SPECIALTY LABORATORY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-15
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
26D0953866OtherCLIA
MO703274407Medicaid
MO703274407Medicaid