Basic Information
| Provider Information | |||||||||
| NPI: | 1285681155 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL LABORATORIES OF MARQUETTE, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5700 SOUTHWYCK BLVD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436141509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002888325 | ||||||||
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| Practice Location | |||||||||
| Address1: | 850 W BARAGA AVE | ||||||||
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| City: | MARQUETTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49855 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9064493000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 08/11/2022 | ||||||||
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| AuthorizedOfficialLastName: | WEISS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9062289440 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 134318200 | 01 | MI | US DEPT OF LABOR | OTHER | 0E26202 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 01186 | 01 | MI | PRIORITY HEALTH | OTHER | CA3542 | 01 | MI | RAILROAD MEDICARE | OTHER | XX19302 | 01 | MI | HEALTHPLUS OF MICHIGAN | OTHER | 21270900 | 05 | WI | MEDICAID |