1285618447 NPI number — PATHOLOGY LABORATORY, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285618447 NPI number — PATHOLOGY LABORATORY, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATHOLOGY LABORATORY, P.C.
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 LABORATORY, P.C.
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:
1285618447
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2620 HORIZON DR SE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49546-7520
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-530-3344
Provider Business Mailing Address Fax Number:
616-530-0575

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2620 HORIZON DRIVE SE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49546-7936
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-530-3344
Provider Business Practice Location Address Fax Number:
616-530-0575
Provider Enumeration Date:
12/01/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MILLS
Authorized Official First Name:
KIM
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
616-530-3344

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X , with the licence number:  23D0380021 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X , with the licence number: 23D0380021 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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