1053394080 NPI number — WESTERN MICHIGAN PATHOLOGY ASSOCIATES, LLC

Table of content: DR. LISA CHARLEEN COWLEY PSYD, LP (NPI 1366479347)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053394080 NPI number — WESTERN MICHIGAN PATHOLOGY ASSOCIATES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTERN MICHIGAN PATHOLOGY ASSOCIATES, LLC
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:
1053394080
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/13/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5700 SOUTHWYCK BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43614-1509
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-288-8325
Provider Business Mailing Address Fax Number:
419-866-5453

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
602 MICHIGAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLLAND
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49423-4918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-392-5141
Provider Business Practice Location Address Fax Number:
419-866-5453
Provider Enumeration Date:
11/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CARR
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
616-394-3185

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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