Provider Demographics
NPI:1962475780
Name:HOSPITAL CONSOLIDATED LABORATORIES
Entity type:Organization
Organization Name:HOSPITAL CONSOLIDATED LABORATORIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:R
Authorized Official - Last Name:HERSCHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-849-3266
Mailing Address - Street 1:22255 GREENFIELD RD
Mailing Address - Street 2:SUITE #501
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-3710
Mailing Address - Country:US
Mailing Address - Phone:248-226-6163
Mailing Address - Fax:248-424-9844
Practice Address - Street 1:23775 NORTHWESTERN HWY
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3338
Practice Address - Country:US
Practice Address - Phone:248-355-9622
Practice Address - Fax:248-355-3557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-10
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3348443Medicaid
MI690F3161000OtherBLUE CROSS BLUE SHIELD
MI3381519Medicaid
MI3348443Medicaid
MIOM54950Medicare ID - Type Unspecified