Provider Demographics
NPI:1679518971
Name:MERITUS MEDICAL LABORATORY LLC
Entity type:Organization
Organization Name:MERITUS MEDICAL LABORATORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:REPAC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-790-9351
Mailing Address - Street 1:11110 MEDICAL CAMPUS RD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-6700
Mailing Address - Country:US
Mailing Address - Phone:301-665-4900
Mailing Address - Fax:301-665-4949
Practice Address - Street 1:11110 MEDICAL CAMPUS RD
Practice Address - Street 2:SUITE 230
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6700
Practice Address - Country:US
Practice Address - Phone:301-665-4900
Practice Address - Fax:301-665-4949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD134291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV5580431Medicaid
214847OtherMDIPA/MAMSI/UHC
MD411588104Medicaid
214847OtherMDIPA/MAMSI/UHC