14D1046049 CLIA NUMBER - MASSAC MEMORIAL MEDICAL CLINIC MASSAC MEMORIAL HOSPITAL

Laboratory Demographics

  • CLIA Code: 14D1046049
  • Facility Name: MASSAC MEMORIAL MEDICAL CLINIC MASSAC MEMORIAL HOSPITAL
  • Facility Address: 1204 W 10TH ST - STE A & B
    METROPOLIS, IL
    ZIP 62960
  • Facility Phone: 618 524-3572
  • Facility Type: Rural Health Clinic
  • Facility Type: Waiver
  • Lab Director: JONATHAN E. WALTERS M D
  • NPI Number: 1740355809
  • Taxonomy: 261QR1300X - Clinic/Center

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CLIA Record

Field Name Field Value
CLIA Number 14D1046049
LAB Type Rural Health Clinic
Facility Name MASSAC MEMORIAL MEDICAL CLINIC MASSAC MEMORIAL HOSPITAL
Street 1204 W 10TH ST - STE A & B
City METROPOLIS
State IL
ZIP 62960
Phone 618 524-3572
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 9/29/2025
Certificate Expiration Date 9/28/2027
Facility Type Rural Health Clinic
Lab Director JONATHAN E. WALTERS M D

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