Provider Demographics
NPI:1134210297
Name:ANGIOGRAPHIC LABORATORY, LLC
Entity type:Organization
Organization Name:ANGIOGRAPHIC LABORATORY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:FREDERICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-375-3812
Mailing Address - Street 1:95 ARCH ST
Mailing Address - Street 2:SUITE 115
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44304-1437
Mailing Address - Country:US
Mailing Address - Phone:330-375-6520
Mailing Address - Fax:330-375-6521
Practice Address - Street 1:95 ARCH ST
Practice Address - Street 2:SUITE 115
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44304-1437
Practice Address - Country:US
Practice Address - Phone:330-375-6520
Practice Address - Fax:330-375-6521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2480337Medicaid
OH2480337Medicaid