Provider Demographics
NPI:1871526384
Name:BOSTWICK LABORATORIES INC
Entity type:Organization
Organization Name:BOSTWICK LABORATORIES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:STEFANELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-512-5200
Mailing Address - Street 1:PO BOX 403751
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-3751
Mailing Address - Country:US
Mailing Address - Phone:804-967-9225
Mailing Address - Fax:804-239-1954
Practice Address - Street 1:6925 LAKE ELLENOR DR
Practice Address - Street 2:SUITE 2
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-4631
Practice Address - Country:US
Practice Address - Phone:407-888-9937
Practice Address - Fax:407-856-0333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA138056OtherANTHEM BCBS OF VIRGINIA
FL911980901Medicaid
OH000000265151Medicaid
UT1871526384Medicaid
VA1871526384Medicaid
WI100003924Medicaid
CO93355076Medicaid
IN200931860AMedicaid
NC7001363Medicaid
SCL00257Medicaid
CT003124823Medicaid
LA1632939Medicaid
OK200024720CMedicaid
AZ441761Medicaid
NM68730055Medicaid
IA1871526384Medicaid
WA7147838Medicaid
PA1009021320005Medicaid
WY127455400Medicaid
AL1871526384Medicaid
SCL00257Medicaid
CO93355076Medicaid
NC7001363Medicaid
FLE9144Medicare PIN