Provider Demographics
NPI:1528098787
Name:PARKWAY CLINICAL LABORATORY, INC.
Entity type:Organization
Organization Name:PARKWAY CLINICAL LABORATORY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LAB MANAGER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-362-1310
Mailing Address - Street 1:381 FOREST PKWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:FOREST PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30297-2165
Mailing Address - Country:US
Mailing Address - Phone:404-362-1310
Mailing Address - Fax:404-362-1355
Practice Address - Street 1:381 FOREST PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:FOREST PARK
Practice Address - State:GA
Practice Address - Zip Code:30297-2165
Practice Address - Country:US
Practice Address - Phone:404-362-1310
Practice Address - Fax:404-362-1355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031-032291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA69WBDHRMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER