Healthcare Provider Details

I. General information

NPI: 1790027837
Provider Name (Legal Business Name): PHYSICIANS REFERENCE LABORATORY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2013
Last Update Date: 03/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 NW R D MIZE RD STE 218
BLUE SPRINGS MO
64014-2510
US

IV. Provider business mailing address

7800 W 110TH ST
OVERLAND PARK KS
66210-2304
US

V. Phone/Fax

Practice location:
  • Phone: 913-338-4070
  • Fax: 913-338-4245
Mailing address:
  • Phone: 913-338-4070
  • Fax: 913-338-4245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207ZP0007X
TaxonomyMolecular Genetic Pathology (Pathology) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. GREGORY J KEITGES
Title or Position: COO
Credential:
Phone: 913-338-4070