MEDICARE: MID AMERICA CLINICAL LABORATORIES, 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	15D1011663	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	7183102	OTHER	IN	CAP
3	15D1011663	OTHER	IN	CLIA

General Provider Information

NPI Number	:	1104885052
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MID AMERICA CLINICAL LABORATORIES, LLC

Provider Business Mailing Address
First Line	:	2560 N SHADELAND AVE
Second Line	:	P.O. BOX 19163
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46219-1705
Country	:	US
Telephone Number	:	317-803-1010
Fax Number	:	317-803-0186

Provider Business Practice Location Address
First Line	:	1950 W 86TH ST
Second Line	:	SUITE 100
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46260-2076
Country	:	US
Telephone Number	:	317-803-0330
Fax Number	:	317-334-0709

Authorized Official
Title or Position	:	C.E.O./GENERAL MANAGER
Name	:	MS. DIANNE Z. VANNESS
Credential	:
Telephone Number	:	317-803-0300

Provider Enumeration Date	:	03/20/2006
Last Update Date	:	09/16/2008

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