Provider Demographics
NPI:1962903575
Name:NEWSTAR MEDICAL LABORATORIES, LLC
Entity type:Organization
Organization Name:NEWSTAR MEDICAL LABORATORIES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:GODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-505-8016
Mailing Address - Street 1:975 COBB PLACE BLVD NW STE 218
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-4802
Mailing Address - Country:US
Mailing Address - Phone:678-505-8016
Mailing Address - Fax:
Practice Address - Street 1:975 COBB PLACE BLVD NW STE 218
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-4802
Practice Address - Country:US
Practice Address - Phone:678-505-8016
Practice Address - Fax:678-806-7192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-28
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD146207500Medicaid
GA003211136AMedicaid
AL222806Medicaid