MEDICARE: QUEST DIAGNOSTICS MASSACHUSETTS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1134421522
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUEST DIAGNOSTICS MASSACHUSETTS LLC

Provider Business Mailing Address
First Line	:	1001 ADAMS AVE MRGOV
Second Line	:	2ND FLOOR
City	:	NORRISTOWN
State	:	PA
Zip	:	19403-2429
Country	:	US
Telephone Number	:	484-676-7000
Fax Number	:	484-676-5309

Provider Business Practice Location Address
First Line	:	31 PINE ST
Second Line	:	1ST FLOOR, REAR
City	:	NORFOLK
State	:	MA
Zip	:	02056-1642
Country	:	US
Telephone Number	:	508-384-1412
Fax Number	:

Authorized Official
Title or Position	:	VP OF REVENUE SERVICES
Name	:	J PABLO LAKE
Credential	:
Telephone Number	:	484-676-7000

Provider Enumeration Date	:	11/17/2010
Last Update Date	:	07/31/2015

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