MEDICARE: MIDWAY SPECIALTY DIAGNOSTICS 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	:	1710696398
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWAY SPECIALTY DIAGNOSTICS LLC

Provider Business Mailing Address
First Line	:	356 E MIDWAY RD
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34982-7148
Country	:	US
Telephone Number	:	772-464-9746
Fax Number	:

Provider Business Practice Location Address
First Line	:	3255 S US HIGHWAY 1
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34982-6381
Country	:	US
Telephone Number	:	772-464-9746
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	ANAND SUKHRAM
Credential	:
Telephone Number	:	772-464-9746

Provider Enumeration Date	:	11/22/2022
Last Update Date	:	11/22/2022

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