1881746253 NPI number — PERMIAN PATHOLOGY ASSOC

Table of content: (NPI 1881746253)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881746253 NPI number — PERMIAN PATHOLOGY ASSOC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERMIAN PATHOLOGY ASSOC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1881746253
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 ADAMS AVE
Provider Second Line Business Mailing Address:
STE 400
Provider Business Mailing Address City Name:
ODESSA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79761
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
432-333-2934
Provider Business Mailing Address Fax Number:
432-333-3719

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 ADAMS AVE
Provider Second Line Business Practice Location Address:
STE 400
Provider Business Practice Location Address City Name:
ODESSA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79761
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-333-2934
Provider Business Practice Location Address Fax Number:
432-333-3719
Provider Enumeration Date:
01/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CHALLAPALLI
Authorized Official First Name:
KRIS
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
432-333-2934

Provider Taxonomy Codes

  • Taxonomy code: 207ZC0500X , with the licence number:  E5030 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207ZC0500X , with the licence number: L2372 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207ZP0101X , with the licence number: E5030 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207ZP0101X , with the licence number: L2372 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8563N0 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8563N1 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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