21D0220530 CLIA NUMBER - PRAVEEN BOLARUM MD LLC

Laboratory Demographics

  • CLIA Code: 21D0220530
  • Facility Name: PRAVEEN BOLARUM MD LLC
  • Facility Address: 196 THOMAS JOHNSON DRIVE SUITE 135
    FREDERICK, MD
    ZIP 21702
  • Facility Phone: 301 694-6688
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: PRAVEEN K. BOLARUM MD
  • NPI Number: 1073575015
  • Taxonomy: 207Q00000X - Family Medicine

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CLIA Record

Field Name Field Value
CLIA Number 21D0220530
LAB Type Physician Office
Facility Name PRAVEEN BOLARUM MD LLC
Street 196 THOMAS JOHNSON DRIVE SUITE 135
City FREDERICK
State MD
ZIP 21702
Phone 301 694-6688
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 9/1/2024
Certificate Expiration Date 8/31/2026
Facility Type Physician Office
Lab Director PRAVEEN K. BOLARUM MD

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