MEDICARE: MEDICAL DIAGNOSTIC 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	32714	OTHER	IL	GHP
2	3509010	OTHER	IL	UHC
3	110795	OTHER	IL	HEALTHLINK
4	31251	OTHER	MO	BCBS OF MISSOURI
5	50000463	OTHER	IL	BCBS OF ILLINOIS

General Provider Information

NPI Number	:	1699706770
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICAL DIAGNOSTIC LABORATORY, INC

Provider Business Mailing Address
First Line	:	45 SHEFFIELD DR
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62223-3557
Country	:	US
Telephone Number	:	618-233-0522
Fax Number	:

Provider Business Practice Location Address
First Line	:	45 SHEFFIELD DR
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62223-3557
Country	:	US
Telephone Number	:	618-233-0522
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. PAUL PONGPITOON
Credential	:	MT(ASCP) M.P.H.
Telephone Number	:	618-233-0522

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	08/22/2020

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