MEDICARE: IDTS-MOBILE SPECIMEN COLLECTION LAB 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	207ZC0006X	Clinical Pathology Physician
2	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1417847310
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDTS-MOBILE SPECIMEN COLLECTION LAB LLC

Provider Business Mailing Address
First Line	:	3849 SAINT BARNABAS RD APT T2
Second Line	:
City	:	SUITLAND
State	:	MD
Zip	:	20746-3238
Country	:	US
Telephone Number	:	240-350-2943
Fax Number	:	866-528-1035

Provider Business Practice Location Address
First Line	:	3849 SAINT BARNABAS RD APT T2
Second Line	:
City	:	SUITLAND
State	:	MD
Zip	:	20746-3238
Country	:	US
Telephone Number	:	240-350-2943
Fax Number	:	866-528-1035

Authorized Official
Title or Position	:	OWNER/DOT COLLECTOR
Name	:	MS. PHYLLIS SMITH
Credential	:	NA
Telephone Number	:	240-350-2943

Provider Enumeration Date	:	07/03/2025
Last Update Date	:	01/09/2026

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