Provider Demographics
NPI:1053483438
Name:HOLMES DIAGNOSTIC LABORATORY INC
Entity type:Organization
Organization Name:HOLMES DIAGNOSTIC LABORATORY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LAB SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:YERSE
Authorized Official - Suffix:
Authorized Official - Credentials:MLT ASCP
Authorized Official - Phone:330-674-6850
Mailing Address - Street 1:1245 GLEN DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MILLERSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44654
Mailing Address - Country:US
Mailing Address - Phone:330-674-6850
Mailing Address - Fax:866-947-0048
Practice Address - Street 1:1245 GLEN DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:MILLERSBURG
Practice Address - State:OH
Practice Address - Zip Code:44654
Practice Address - Country:US
Practice Address - Phone:330-674-6850
Practice Address - Fax:866-947-0048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000155845OtherANTHEM
OH0121960Medicaid
000000155845OtherANTHEM
HOD368271Medicare ID - Type Unspecified