Provider Demographics
NPI:1447506787
Name:SUBURBAN MEDICAL LABORATORY, INC.
Entity type:Organization
Organization Name:SUBURBAN MEDICAL LABORATORY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, BILLING OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:ELMER
Authorized Official - Last Name:HOSKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-752-7300
Mailing Address - Street 1:665 OHIO PIKE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45245-2117
Mailing Address - Country:US
Mailing Address - Phone:513-752-7300
Mailing Address - Fax:513-201-0013
Practice Address - Street 1:39303 COUNTRY CLUB DR
Practice Address - Street 2:SUITE C-30
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48331-3478
Practice Address - Country:US
Practice Address - Phone:513-752-7300
Practice Address - Fax:513-201-0013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-24
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36D0339673291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0288004Medicaid
OH36D0339673OtherCLIA
OH36D0339673OtherCLIA
SU3681581Medicare UPIN