MEDICARE: PROFESSIONAL CLINICAL LABORATORY, INC

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	36D2050322	OH

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
10	690008760	OTHER		RAILROAD MEDICARE

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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	CL5046	OTHER	TX	BLUE CROSS BLUESHIELD
8	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
9	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1255672176
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL CLINICAL LABORATORY, INC

Provider Business Mailing Address
First Line	:	6660 DOUBLETREE AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43229-1128
Country	:	US
Telephone Number	:	866-776-5221
Fax Number	:	682-647-6238

Provider Business Practice Location Address
First Line	:	3020 WICHITA CT
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76140-1710
Country	:	US
Telephone Number	:	866-776-5221
Fax Number	:	682-647-6238

Authorized Official
Title or Position	:	COO/VICE PRESIDENT
Name	:	MRS. HOLLY RENEA SHIELDS
Credential	:
Telephone Number	:	866-776-5221

Provider Enumeration Date	:	03/04/2013
Last Update Date	:	03/04/2013

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