MEDICARE: MIDWEST MEDICAL 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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1568974913
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWEST MEDICAL LAB LLC

Provider Business Mailing Address
First Line	:	1916 N REYNOLDS RD
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43615-3510
Country	:	US
Telephone Number	:	248-234-8617
Fax Number	:	888-298-9165

Provider Business Practice Location Address
First Line	:	1916 N REYNOLDS RD
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43615-3510
Country	:	US
Telephone Number	:	248-234-8617
Fax Number	:	888-298-9165

Authorized Official
Title or Position	:	OWNER
Name	:	FOUAD BAYDOUN
Credential	:
Telephone Number	:	313-544-3614

Provider Enumeration Date	:	10/25/2017
Last Update Date	:	10/25/2017

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