1295894970 NPI number — DERMATOPATHOLOGY LABORATORY OF THE MIDSOUTH INC

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 1295894970 NPI number — DERMATOPATHOLOGY LABORATORY OF THE MIDSOUTH INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMATOPATHOLOGY LABORATORY OF THE MIDSOUTH 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:
1295894970
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:
4301 HILLSBORO PIKE
Provider Second Line Business Mailing Address:
SUITE 222
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37215-3345
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-386-9719
Provider Business Mailing Address Fax Number:
615-386-0587

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4301 HILLSBORO PIKE
Provider Second Line Business Practice Location Address:
SUITE 222
Provider Business Practice Location Address City Name:
NASHVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37215-3345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-386-9719
Provider Business Practice Location Address Fax Number:
615-386-0587
Provider Enumeration Date:
12/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FIELDS
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
P
Authorized Official Title or Position:
AUTHORIZED OFFICIAL OF ORGANIZATION
Authorized Official Telephone Number:
615-386-9719

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  2178 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 291U00000X , with the licence number: 207N00000X , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3401879 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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