Provider Demographics
NPI:1053335729
Name:MOLECULAR PATHOLOGY LABORATORY NETWORK INC
Entity type:Organization
Organization Name:MOLECULAR PATHOLOGY LABORATORY NETWORK INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:HUBBARD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:865-380-9746
Mailing Address - Street 1:250 EAST BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37804-5782
Mailing Address - Country:US
Mailing Address - Phone:865-380-9746
Mailing Address - Fax:865-380-9191
Practice Address - Street 1:250 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5782
Practice Address - Country:US
Practice Address - Phone:865-380-9746
Practice Address - Fax:865-273-1129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000003348291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4067281OtherBCBS PROVIDER NUMBER
TN3404226Medicaid
TN4067281OtherBCBS PROVIDER NUMBER
TN3404226Medicare ID - Type UnspecifiedLABORATORY PROVIDER NUMBE