MEDICARE: APOLLO DIAGNOSTICS LABORATORY INC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	291U00000X	OTHER	MI	TAXONOMY

General Provider Information

NPI Number	:	1710237870
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	APOLLO DIAGNOSTICS LABORATORY INC

Provider Business Mailing Address
First Line	:	21999 FARMINGTON RD
Second Line	:	SUITE 100
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48336-4400
Country	:	US
Telephone Number	:	248-615-3100
Fax Number	:	248-615-0136

Provider Business Practice Location Address
First Line	:	21999 FARMINGTON RD
Second Line	:	SUITE 100
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48336-4400
Country	:	US
Telephone Number	:	248-615-3100
Fax Number	:	248-615-0136

Authorized Official
Title or Position	:	OWNER
Name	:	BASSAM MANSOOR
Credential	:
Telephone Number	:	248-615-3100

Provider Enumeration Date	:	09/17/2012
Last Update Date	:	09/17/2012

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