Healthcare Provider Details

I. General information

NPI: 1841358173
Provider Name (Legal Business Name): MADISON AVENUE MEDICAL LABORATORY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 05/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8523 MADISON AVENUE SUITE B
INDIANAPOLIS IN
46227
US

IV. Provider business mailing address

8523 MADISON AVENUE SUITE B
INDIANAPOLIS IN
46227
US

V. Phone/Fax

Practice location:
  • Phone: 317-887-6407
  • Fax: 317-887-6309
Mailing address:
  • Phone: 317-887-6407
  • Fax: 317-887-6309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: LARRY WAYNE MILLER
Title or Position: PRESIDENT
Credential:
Phone: 317-887-6407