MEDICARE: ATLANTIC DIAGNOSTICS LABORATORIES

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	024997	PA

General Provider Information

NPI Number	:	1164660643
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATLANTIC DIAGNOSTICS LABORATORIES

Provider Business Mailing Address
First Line	:	1570 GARRETT RD
Second Line	:
City	:	UPPER DARBY
State	:	PA
Zip	:	19082-4500
Country	:	US
Telephone Number	:	215-858-8801
Fax Number	:

Provider Business Practice Location Address
First Line	:	1570 GARRETT RD
Second Line	:
City	:	UPPER DARBY
State	:	PA
Zip	:	19082-4500
Country	:	US
Telephone Number	:	215-858-8801
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. PASCHAL B DEJOHN
Credential	:
Telephone Number	:	215-858-8801

Provider Enumeration Date	:	01/22/2009
Last Update Date	:	01/22/2009

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