Provider Demographics
NPI:1750374088
Name:SHIEL MEDICAL LABORATORY, INC
Entity type:Organization
Organization Name:SHIEL MEDICAL LABORATORY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GITTY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-552-1000
Mailing Address - Street 1:63 FLUSHING AVE
Mailing Address - Street 2:UNIT 336
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11205-1005
Mailing Address - Country:US
Mailing Address - Phone:718-552-1000
Mailing Address - Fax:718-875-5017
Practice Address - Street 1:63 FLUSHING AVE
Practice Address - Street 2:UNIT 336
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11205-1005
Practice Address - Country:US
Practice Address - Phone:718-552-1000
Practice Address - Fax:718-875-5017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-23
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3709291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0016539OtherGHI
NJ5127807OtherNJ MEDICAID #
NY0016539OtherGHI