MEDICARE: EAGLE LABS 2 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	207ZP0007X	Molecular Genetic Pathology (Pathology) Physician

General Provider Information

NPI Number	:	1134725690
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAGLE LABS 2 LLC

Provider Business Mailing Address
First Line	:	4 WILLOW PT
Second Line	:
City	:	HATTIESBURG
State	:	MS
Zip	:	39402-1150
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4 WILLOW PT
Second Line	:
City	:	HATTIESBURG
State	:	MS
Zip	:	39402-1150
Country	:	US
Telephone Number	:	601-898-7530
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	KATIE MCDONNIEAL
Credential	:
Telephone Number	:	601-425-4893

Provider Enumeration Date	:	12/09/2020
Last Update Date	:	12/09/2020

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