Organization
MEDICAL DIAGNOSTIC LABORATORY, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. PAUL PONGPITOON MT(ASCP) M.P.H. (PRESIDENT)
(618) 233-0522
Entity
Organization
Contact information
Practice address
45 SHEFFIELD DR, BELLEVILLE, IL 62223-3557
(618) 233-0522
Mailing address
45 SHEFFIELD DR, BELLEVILLE, IL 62223-3557
(618) 233-0522
Taxonomy
Speciality
Code
Description
License number
State
291U00000X
Clinical Medical Laboratory
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
110795
HEALTHLINK
IL
01
—
31251
BCBS OF MISSOURI
MO
01
—
32714
GHP
IL
01
—
3509010
UHC
IL
01
—
50000463
BCBS OF ILLINOIS
IL
Enumeration date
07/06/2006
Last updated
08/22/2020
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