MEDICARE: IPSUM 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	11D2125186	GA

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	060-403	OTHER	GA	GA LICENSE
3	45D2299234	OTHER	TX	CLIA NUMBER
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164962882
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IPSUM DIAGNOSTICS LLC

Provider Business Mailing Address
First Line	:	8607 ROBERTS DR STE 250
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30350-2237
Country	:	US
Telephone Number	:	678-915-2299
Fax Number	:	833-964-0184

Provider Business Practice Location Address
First Line	:	8607 ROBERTS DR STE 250
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30350-2237
Country	:	US
Telephone Number	:	678-915-2299
Fax Number	:	833-964-0184

Authorized Official
Title or Position	:	MANAGER
Name	:	COLIN ROGERS
Credential	:
Telephone Number	:	404-441-8180

Provider Enumeration Date	:	02/28/2017
Last Update Date	:	02/22/2024

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Directions to “IPSUM DIAGNOSTICS LLC ” Practice Location

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