Organization
FIRSTSOURCE LABORATORY SOLUTIONS, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. KIMBERELY GRADDY (PRESIDENT)
(317) 566-9846
Entity
Organization
Contact information
Practice address
10022 LANTERN RD, SUITE 600, FISHERS, IN 46037-9601
(317) 566-9846
(317) 566-9847
Mailing address
10022 LANTERN RD, SUITE 600, FISHERS, IN 46037-9601
(317) 566-9846
(317) 566-9847
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
01040224A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000345223
BLUE SHIELD PROVIDER #
IN
Enumeration date
06/30/2006
Last updated
08/22/2020
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