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General NPI Number Information
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NPI Number | 1790829117
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Entity Type | Organization
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Legal Business Name | SOUTHERN IILINOIS PATHOLOGY LABORATORY LTD
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Dates
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Enumeration Date | 02/18/2007
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Last Update Date | 01/14/2008
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Provider Practice Location Address
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Address Line | 6111 VOLLMER LN
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City | GODFREY
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State | IL
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Zip | 62035-1062
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Country | US
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Telephone | 618-466-3645
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Fax | 618-466-3410
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Provider Business Mailing Address
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Address Line | PO BOX 1166
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City | ALTON
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State | IL
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Zip | 62002-1166
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Country | US
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Telephone | 618-466-3645
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Fax | 618-466-3410
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Authorized Official
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Title or Position | LABORATORY DIRECTOR
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Name | ORDIE H KING JR.
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Credential | D D S PH D
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Telephone | 618-466-3645
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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 |
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License Number State |
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