| Field | Value |
|---|---|
|
CCN
| 25D2006846 |
|
Provider Category Subtype Code
| Clia88 Laboratory |
|
Provider Category Code
| Clia Laboratory |
|
CHOW Count
| 0 |
|
CHOW Date
| |
|
Address: City
| Hattiesburg |
|
Compliance: Acceptable POC
| N |
|
Compliance: Status
| |
|
SSA County Code
| 170 |
| Field (click for description) | Value |
|
Cross Ref Provider Number
| |
|
Certification Date
| April 30, 2010 |
|
Eligibility Indicator
| N |
|
Facility Name
| Hubcare Pathology Pa At Wesley Medical Center |
|
Medicare Administrative Contractor (MAC) orIntermediary or Carrier Code
| |
|
Medicaid Vendor Number
| |
|
Original Participation Date
| April 30, 2010 |
|
Prior CHOW Date
| |
|
Prior Medicare Administrative Contractor (MAC) orIntermediary or Carrier Code
| |
|
Region Code
| Atlanta |
| Field (click for description) | Value |
|
Skeleton Record Indicator
| Y |
|
State Abbreviation
| Mississippi |
|
SSA State Code
| Mississippi |
|
State Region Code
| 001 |
|
Address: Street
| 5001 Hardy Street |
|
Telephone Number
| (601) 268-5995 |
|
Termination Code
| Active Provider |
|
Termination or Expiration Date
| October 05, 2022 |
|
Type of Action Code
| Initial |
|
Ownership Type Code
| PROPRIETARY |
| Field (click for description) | Value |
|
Address: ZIP Code
| 39402 |
|
FIPS State Code
| Mississippi |
|
FIPS County Code
| 035 |
|
CBSA Urban Rural Indicator
| U |
|
CBSA Code
| 25620 |
|
Address: Street 2nd Line
| |
|
Affiliated Provider Number 1
| |
|
Affiliated Provider Number 2
| |
|
Affiliated Provider Number 3
| |
|
Affiliated Provider Number 4
| |
| Field (click for description) | Value |
|
Affiliated Provider Number 5
| |
|
Affiliated Provider Number 6
| |
|
Affiliated Provider Number 7
| |
|
Affiliated Provider Number 8
| |
|
AO A2LA Accredited Code
| |
|
AO A2LA Accredited Y Match Date
| |
|
AO A2LA Accredited Y Match Indicator
| N |
|
AO AABB Accredited Code
| |
|
AO AABB Accredited Y Match Date
| |
|
AO AABB Accredited Y Match Indicator
| N |
| Field (click for description) | Value |
|
AO AOA Accredited Code
| |
|
AO AOA Accredited Y Match Date
| |
|
AO AOA Accredited Y Match Indicator
| N |
|
AO ASHI Accredited Code
| |
|
AO ASHI Accredited Y Match Date
| |
|
AO ASHI Accredited Y Match Indicator
| N |
|
AO CAP Accredited Code
| Accredited |
|
AO CAP Accredited Y Match Date
| October 06, 2010 |
|
AO CAP Accredited Y Match Indicator
| Y |
|
AO COLA Accredited Code
| |
| Field (click for description) | Value |
|
AO COLA Accredited Y Match Date
| |
|
AO COLA Accredited Y Match Indicator
| N |
|
AO JC Accredited Code
| |
|
AO JC Accredited Y Match Date
| |
|
AO JC Accredited Y Match Indicator
| N |
|
Application Received SA Date
| April 30, 2010 |
|
Application Type Code
| Accreditation |
|
Category-specific Facility Type Code
| Independent |
|
CLIA Certificate Effective Date
| October 06, 2020 |
|
CLIA Certificate Mailed Date
| September 08, 2020 |
| Field (click for description) | Value |
|
CLIA Certificate Type Code
| Accreditation |
|
Current CLIA Lab Clsfctn CD
| Clia Laboratory |
|
CLIA Lab Classification CD 1
| Clia Laboratory |
|
CLIA Lab Classification CD 10
| |
|
CLIA Lab Classification CD 2
| Clia Laboratory |
|
CLIA Lab Classification CD 3
| Clia Laboratory |
|
CLIA Lab Classification CD 4
| Clia Laboratory |
|
CLIA Lab Classification CD 5
| Clia Laboratory |
|
CLIA Lab Classification CD 6
| Clia Laboratory |
|
CLIA Lab Classification CD 7
| Clia Laboratory |
| Field (click for description) | Value |
|
CLIA Lab Classification CD 8
| |
|
CLIA Lab Classification CD 9
| |
|
CLIA Medicare Number
| |
|
CLIA Termination Code
| Active Provider |
|
CMS-116 Accreditation Schedule Code
| Total Volume: 1 To 2,000 |
|
CMS-116 Accredited Annual Test Volume
| 350 |
|
CMS-116 Annual Test Volume
| 0 |
|
Director Affiliated Lab Count
| 0 |
|
Fax Phone Number
| |
|
Fiscal Year End Date (MMDD)
| |
| Field (click for description) | Value |
|
Multiple Site Certificate Indicator
| N |
|
Multiple Site Exception: Hospital Campus Indicator
| N |
|
Multiple Site Exception: Public Health Indicator
| N |
|
Multiple Site Exception: Temporary Testing SiteIndicator
| N |
|
Multiple Site Lab Count
| 0 |
|
PPM Test Volume Count
| 0 |
|
Provider Name 2nd Line
| |
|
Related Provider Number
| |
|
Shared Lab Indicator
| N |
|
Shared Lab Xref Number
| |
| Field (click for description) | Value |
|
Survey Compliance Certificate Schedule Code
| |
|
Survey Compliance Schedule Code
| |
|
Survey Test Volume Count
| 0 |
|
Waived Test Volume Count
| 0 |
© LabProspects 2020