Provider Demographics
NPI:1538542196
Name:PROTEUS MOLECULAR AND CLINICAL LAB LLC
Entity type:Organization
Organization Name:PROTEUS MOLECULAR AND CLINICAL LAB LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRIFFITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-820-0115
Mailing Address - Street 1:218 SUMMIT PKWY
Mailing Address - Street 2:SUITE 250
Mailing Address - City:HOMEWOOD
Mailing Address - State:AL
Mailing Address - Zip Code:35209-4732
Mailing Address - Country:US
Mailing Address - Phone:205-820-0115
Mailing Address - Fax:
Practice Address - Street 1:218 SUMMIT PKWY
Practice Address - Street 2:SUITE 250
Practice Address - City:HOMEWOOD
Practice Address - State:AL
Practice Address - Zip Code:35209
Practice Address - Country:US
Practice Address - Phone:205-820-0115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-01
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL198878Medicaid