MEDICARE: CAROLINA MEDICAL LAB GROUP 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	34D0946272	NC

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

General Provider Information

NPI Number	:	1992700124
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLINA MEDICAL LAB GROUP INC.

Provider Business Mailing Address
First Line	:	1815 BACK CREEK DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28213-2159
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1815 BACK CREEK DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28213-2159
Country	:	US
Telephone Number	:	704-598-8818
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. OSAMA IDLIBI
Credential	:
Telephone Number	:	704-598-8818

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	07/27/2009

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