MEDICARE: PHYSICIANS REFERENCE LABORATORY LLC

Medicare Provider Information

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

#	Taxonomy Code	Taxonomy
1	291U00000X	Clinical Medical Laboratory
2	207ZP0101X	Anatomic Pathology Physician
3	207ZB0001X	Blood Banking & Transfusion Medicine Physician
4	207ZC0500X	Cytopathology Physician
5	207ZD0900X	Dermatopathology (Pathology) Physician
6	207ZP0007X	Molecular Genetic Pathology (Pathology) Physician
7	207ZN0500X	Neuropathology Physician
8	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DD5377	OTHER	MO	RAILROAD MEDICARE

NPI Number	:	1326053133
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICIANS REFERENCE LABORATORY LLC

Provider Business Mailing Address
First Line	:	7800 W 110TH ST
Second Line	:	STE 200
City	:	OVERLAND PARK
State	:	KS
Zip	:	66210-2304
Country	:	US
Telephone Number	:	913-338-4070
Fax Number	:	913-338-4245

Provider Business Practice Location Address
First Line	:	201 W R D MIZE RD
Second Line	:
City	:	BLUE SPRINGS
State	:	MO
Zip	:	64015-2518
Country	:	US
Telephone Number	:	913-338-4070
Fax Number	:	913-338-4245

Authorized Official
Title or Position	:	COO
Name	:	MR. GREGORY J KEITGES
Credential	:
Telephone Number	:	913-338-4070

Provider Enumeration Date	:	07/30/2006
Last Update Date	:	07/31/2012

3704 NW BRIARWOOD DR
BLUE SPRINGS, MO
64015-2518

Practice Phone: 816-665-9013
Practice Fax: 816-228-6949