Provider Demographics
NPI:1699706770
Name:MEDICAL DIAGNOSTIC LABORATORY, INC
Entity type:Organization
Organization Name:MEDICAL DIAGNOSTIC LABORATORY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:PONGPITOON
Authorized Official - Suffix:
Authorized Official - Credentials:MT(ASCP) MPH
Authorized Official - Phone:618-233-0522
Mailing Address - Street 1:45 SHEFFIELD DR
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-3557
Mailing Address - Country:US
Mailing Address - Phone:618-233-0522
Mailing Address - Fax:
Practice Address - Street 1:45 SHEFFIELD DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-3557
Practice Address - Country:US
Practice Address - Phone:618-233-0522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL32714OtherGHP
IL3509010OtherUHC
IL110795OtherHEALTHLINK
MO31251OtherBCBS OF MISSOURI
IL50000463OtherBCBS OF ILLINOIS
IL=========001Medicaid
MO31251OtherBCBS OF MISSOURI
IL148475Medicare ID - Type UnspecifiedTECHNICAL COMPONENT