1245302009 NPI number — MID-ATLANTIC PATHOLOGY SERVICES, INC.

Table of content: (NPI 1245302009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245302009 NPI number — MID-ATLANTIC PATHOLOGY SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID-ATLANTIC PATHOLOGY SERVICES, INC.
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:
1245302009
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1355 RIVER BEND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75247-4915
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-638-2000
Provider Business Mailing Address Fax Number:
844-751-9262

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 GLENN DR
Provider Second Line Business Practice Location Address:
SUITE 10-A
Provider Business Practice Location Address City Name:
STERLING
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20164-7119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-404-8189
Provider Business Practice Location Address Fax Number:
703-404-1131
Provider Enumeration Date:
11/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GRATTENDICK
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
561-626-5512

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X , with the licence number: 49D0898222 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: B020 . This is a "CAREFIRST BLUE CROSS DC" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 4109007 00 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 006601812 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200330 . This is a "ANTHEM BLUE CROSS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 6902000000KU90 . This is a "CAREFIRST NATIONAL ACCTS" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: KU90MI . This is a "CAREFIRST OF MARYLAND" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 137554 . This is a "SOUTHERN HEALTHCARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 006601839 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 690007157 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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