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General NPI Number Information
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NPI Number | 1043558992
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Entity Type | Organization
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Legal Business Name | PERSONAL GENOME DIAGNOSTICS
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Dates
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Enumeration Date | 01/28/2013
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Last Update Date | 05/30/2024
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Provider Practice Location Address
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Address Line | 3600 BOSTON ST STE 10
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City | BALTIMORE
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State | MD
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Zip | 21224-5729
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Country | US
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Telephone | 855-743-9669
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Fax | 443-602-8833
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Provider Business Mailing Address
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Address Line | PO BOX 2240
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City | BURLINGTON
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State | NC
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Zip | 27216-2240
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Country | US
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Telephone | 336-222-7566
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Fax | 443-602-8833
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | KIMBERLY T WILLIAMS
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Credential |
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Telephone | 336-436-5402
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 21D2039282
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License Number State | MD
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