MEDICARE: CLONGEN LABORATORIES, 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	1206	MD

General Provider Information

NPI Number	:	1770722100
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLONGEN LABORATORIES, LLC

Provider Business Mailing Address
First Line	:	12321 MIDDLEBROOK RD
Second Line	:	SUITE 120
City	:	GERMANTOWN
State	:	MD
Zip	:	20874-1591
Country	:	US
Telephone Number	:	301-916-0173
Fax Number	:	301-916-0175

Provider Business Practice Location Address
First Line	:	12321 MIDDLEBROOK RD
Second Line	:	SUITE 120
City	:	GERMANTOWN
State	:	MD
Zip	:	20874-1591
Country	:	US
Telephone Number	:	301-916-0173
Fax Number	:	301-916-0175

Authorized Official
Title or Position	:	PRESIDENT AND LABORATORY DIRECTOR
Name	:	DR. AHMED FATHY KILANI
Credential	:	PH.D.
Telephone Number	:	301-916-0173

Provider Enumeration Date	:	02/09/2009
Last Update Date	:	02/09/2009

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