MEDICARE: SOUTHERN DIAGNOSTIC 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

General Provider Information

NPI Number	:	1780990564
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN DIAGNOSTIC LABORATORIES, LLC

Provider Business Mailing Address
First Line	:	2732 7TH AVE S
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35233-3406
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1450 JONES DAIRY RD
Second Line	:
City	:	JASPER
State	:	AL
Zip	:	35501-6106
Country	:	US
Telephone Number	:	205-387-2113
Fax Number	:	205-387-2425

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	MR. ROSS W JONES
Credential	:
Telephone Number	:	334-358-5966

Provider Enumeration Date	:	08/31/2010
Last Update Date	:	08/31/2010

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