Provider Demographics
NPI:1447356811
Name:MARIN MEDICAL LABORATORIES
Entity type:Organization
Organization Name:MARIN MEDICAL LABORATORIES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PATHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KEDAR
Authorized Official - Middle Name:CHE
Authorized Official - Last Name:PRASAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-209-6017
Mailing Address - Street 1:1615 HILL ROAD SUITE B
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947
Mailing Address - Country:US
Mailing Address - Phone:415-209-6983
Mailing Address - Fax:415-898-0870
Practice Address - Street 1:250 BON AIR ROAD
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904
Practice Address - Country:US
Practice Address - Phone:415-925-7174
Practice Address - Fax:415-461-7228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF316040207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB00787FMedicaid
CAZZZ82266ZMedicare PIN