Organization
BROOKSIDE CLINICAL LABORATORY INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JOHN J IACONO BS (OWNER DIRECTOR)
(610) 872-6466
Entity
Organization
Contact information
Practice address
2901 DUTTON MILL RD STE 100, ASTON, PA 19014-2850
(610) 872-6466
(610) 872-7628
Mailing address
2901 DUTTON MILL RD STE 100, ASTON, PA 19014-2850
(610) 872-6466
(610) 872-7628
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
PA000472
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0000991109
—
DE
05
—
0007670710001
—
PA
01
—
398126
BLUE SHIELD
—
05
—
8034907
—
NJ
Enumeration date
03/15/2006
Last updated
11/06/2018
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