03D1045660 CLIA NUMBER - PROVIDENCE GENERAL MEDICINE

Laboratory Demographics

  • CLIA Code: 03D1045660
  • Facility Name: PROVIDENCE GENERAL MEDICINE
  • Facility Address: 9220 N CENTRAL AVE
    PHOENIX, AZ
    ZIP 85020
  • Facility Phone: 602 254-7077
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: GERARDO SICALO-OBORSKY, MD
  • NPI Number: 1164693974
  • Taxonomy: 207R00000X - Internal Medicine

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CLIA Record

Field Name Field Value
CLIA Number 03D1045660
LAB Type Physician Office
Facility Name PROVIDENCE GENERAL MEDICINE
Street 9220 N CENTRAL AVE
City PHOENIX
State AZ
ZIP 85020
Phone 602 254-7077
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 9/20/2025
Certificate Expiration Date 9/19/2027
Facility Type Physician Office
Lab Director GERARDO SICALO-OBORSKY, MD

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This page was last updated on: 9/29/2025