Organization
CLINIC LABORATORY
Active
Parent organization
CARBONDALE CLINIC, S.C.
Organization subpart
Yes
Provider details
NPI number
Legal business name
CARBONDALE CLINIC, S.C.
Authorized official
MR. ALLAN N. NORMAN (CHIEF EXECUTIVE OFFICER)
(618) 457-5200
Entity
Organization
Contact information
Practice address
2601 W MAIN ST, CARBONDALE, IL 62901-1031
(618) 549-5361
(618) 549-5128
Mailing address
2601 W MAIN ST, CARBONDALE, IL 62901-1031
(618) 549-5361
(618) 549-5128
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
044649
HAMP
IL
01
—
148511
LEGACY
IL
01
—
196086
GHP
IL
01
—
461070
HEALTHLINK
IL
01
—
690003493
RR MEDICARE
IL
Enumeration date
12/28/2006
Last updated
05/09/2008
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