14D0940104 CLIA NUMBER - EDGEBROOK DERMATOLOGY, PC

Laboratory Demographics

  • CLIA Code: 14D0940104
  • Facility Name: EDGEBROOK DERMATOLOGY, PC
  • Facility Address: 1639 NORTH ALPINE ROAD, SUITE 360
    ROCKFORD, IL
    ZIP 61107
  • Facility Phone: 815 229-9333
  • Facility Type: Physician Office
  • Facility Type: Microscopy
  • Lab Director: MARIA ROEHRS I. AL BASHA MD
  • NPI Number: 1710049234
  • Taxonomy: 207N00000X - Dermatology

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CLIA Record

Field Name Field Value
CLIA Number 14D0940104
LAB Type Physician Office
Facility Name EDGEBROOK DERMATOLOGY, PC
Street 1639 NORTH ALPINE ROAD, SUITE 360
City ROCKFORD
State IL
ZIP 61107
Phone 815 229-9333
Certificate Type Certificate for Provider-Performed Microscopy Procedures (PPMP)
Certificate Type Description This certificate is issued to a laboratory in which a physician, midlevel practitioner or dentist performs no tests other than the microscopy procedures. This certificate permits the laboratory to also perform waived tests.
Certificate Effective Date 2/5/2024
Certificate Expiration Date 2/4/2026
Facility Type Physician Office
Lab Director MARIA ROEHRS I. AL BASHA MD

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