Provider Demographics
NPI:1043558992
Name:PERSONAL GENOME DIAGNOSTICS
Entity type:Organization
Organization Name:PERSONAL GENOME DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:T
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-436-5402
Mailing Address - Street 1:PO BOX 2240
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27216-2240
Mailing Address - Country:US
Mailing Address - Phone:336-222-7566
Mailing Address - Fax:443-602-8833
Practice Address - Street 1:3600 BOSTON ST STE 10
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-5729
Practice Address - Country:US
Practice Address - Phone:855-743-9669
Practice Address - Fax:443-602-8833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-28
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21D2039282291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
21D2039282OtherCLIA