MEDICARE: PRISM DIAGNOSTICS, 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		KS

General Provider Information

NPI Number	:	1063907376
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRISM DIAGNOSTICS, LLC

Provider Business Mailing Address
First Line	:	1133 COLLEGE AVE
Second Line	:	BUILDING B, SUITE 100
City	:	MANHATTAN
State	:	KS
Zip	:	66502
Country	:	US
Telephone Number	:	785-565-9500
Fax Number	:	785-565-9595

Provider Business Practice Location Address
First Line	:	1133 COLLEGE AVE
Second Line	:	BUILDING C, SUITE 145
City	:	MANHATTAN
State	:	KS
Zip	:	66502-2751
Country	:	US
Telephone Number	:	785-565-9500
Fax Number	:	785-565-9595

Authorized Official
Title or Position	:	OWNER
Name	:	DR. FADI V BEDROS
Credential	:	MD
Telephone Number	:	785-565-9500

Provider Enumeration Date	:	06/28/2018
Last Update Date	:	06/28/2018

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