Provider Demographics
NPI:1699789685
Name:SOUTHERN MEDICAL LABORATORIES INC
Entity type:Organization
Organization Name:SOUTHERN MEDICAL LABORATORIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:JILL
Authorized Official - Last Name:GERALDS
Authorized Official - Suffix:
Authorized Official - Credentials:BILLING SUPERVISOR
Authorized Official - Phone:270-651-2989
Mailing Address - Street 1:1407 N RACE ST STE 3
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-3474
Mailing Address - Country:US
Mailing Address - Phone:270-651-2989
Mailing Address - Fax:270-651-7690
Practice Address - Street 1:1407 N RACE ST STE 3
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-3474
Practice Address - Country:US
Practice Address - Phone:270-651-2989
Practice Address - Fax:270-651-7690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY200129291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
18D0325975OtherCLIA CERTIFICATE NUMBER
000000061985OtherANTHEM KENTUCKY BCBS
KY37901246Medicaid
KY37901246Medicaid