1265407738 NPI number — ST JOSEPHS PATHOLOGY

Table of content: (NPI 1265407738)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265407738 NPI number — ST JOSEPHS PATHOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST JOSEPHS PATHOLOGY
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:
PATHOLOGY ASSOCIATES LTD
Provider Other Organization Name Type Code:
3
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:
1265407738
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 678027
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:
75267-8027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-943-9200
Provider Business Mailing Address Fax Number:
316-652-0340

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 W THOMAS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85013-4409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-406-3000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/20/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
OLIVER
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
AUTHORIZED REPRESENTATIVE
Authorized Official Telephone Number:
623-889-7403

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)

  • Identifier: AX4478 . This is a "HEALTH NET OF AZ" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AZ0182900 . This is a "BCBSAZ" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 454760 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".