36D0866197 CLIA NUMBER - ANTHONY AMIEWALAN MD SC

Laboratory Demographics

  • CLIA Code: 36D0866197
  • Facility Name: ANTHONY AMIEWALAN MD SC
  • Facility Address: 1750 E LAKE SHORE DRIVE SUITE 320
    DECATUR, IL
    ZIP 62521
  • Facility Phone: 217 422-0560
  • Facility Type: Physician Office
  • Facility Type: Microscopy
  • Lab Director: ANTHONY O. AMIEWALAN MD
  • NPI Number: 1053543215
  • Taxonomy: 173000000X - Legal Medicine

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CLIA Record

Field Name Field Value
CLIA Number 36D0866197
LAB Type Physician Office
Facility Name ANTHONY AMIEWALAN MD SC
Street 1750 E LAKE SHORE DRIVE SUITE 320
City DECATUR
State IL
ZIP 62521
Phone 217 422-0560
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 9/1/2024
Certificate Expiration Date 8/31/2026
Facility Type Physician Office
Lab Director ANTHONY O. AMIEWALAN MD

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