Provider Demographics
NPI:1538192224
Name:ST. ELIZABETH'S DIAGNOSTIC
Entity type:Organization
Organization Name:ST. ELIZABETH'S DIAGNOSTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FALLANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-222-5390
Mailing Address - Street 1:1 ELIZABETH PL
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-3445
Mailing Address - Country:US
Mailing Address - Phone:937-222-5390
Mailing Address - Fax:937-222-5331
Practice Address - Street 1:1 ELIZABETH PL
Practice Address - Street 2:2ND FLOOR
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3445
Practice Address - Country:US
Practice Address - Phone:937-222-5390
Practice Address - Fax:937-222-5331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36D1033316291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory