MEDICARE: GLADZIM MEDICAL LABORATORIES 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	CLIA ID 33D1034578	MD

General Provider Information

NPI Number	:	1700039435
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GLADZIM MEDICAL LABORATORIES INC.

Provider Business Mailing Address
First Line	:	159 FRANKLIN ST
Second Line	:	UNIT #3
City	:	BLOOMFIELD
State	:	NJ
Zip	:	07003-4978
Country	:	US
Telephone Number	:	973-619-2622
Fax Number	:	973-677-1181

Provider Business Practice Location Address
First Line	:	108 S MUNN AVE
Second Line	:
City	:	EAST ORANGE
State	:	NJ
Zip	:	07018-3402
Country	:	US
Telephone Number	:	973-619-2622
Fax Number	:	973-677-1181

Authorized Official
Title or Position	:	PRESIDENT & DIRECTOR
Name	:	DR. GLADYS NGOZI IBEZIM
Credential	:	PH.D
Telephone Number	:	973-619-2622

Provider Enumeration Date	:	10/26/2008
Last Update Date	:	02/13/2009

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