Provider Demographics
NPI:1730230947
Name:MEDICAL GENETIC CONSULTANTS INC
Entity type:Organization
Organization Name:MEDICAL GENETIC CONSULTANTS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, OWNER, PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:C
Authorized Official - Last Name:BURKHARDT
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHD
Authorized Official - Phone:228-872-3680
Mailing Address - Street 1:819 DESOTO ST
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-3707
Mailing Address - Country:US
Mailing Address - Phone:228-872-3680
Mailing Address - Fax:228-872-2563
Practice Address - Street 1:819 DESOTO ST
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-3707
Practice Address - Country:US
Practice Address - Phone:228-872-3680
Practice Address - Fax:228-872-2563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1552976Medicaid
MS00119936Medicaid
AL009918250Medicaid
MS25D0651912OtherCLIA NUMBER
MS690258049Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
MS00119936Medicaid