1497718100 NPI number — PATHOLOGY ASSOCIATES OF BOONE PC

Table of content: (NPI 1497718100)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497718100 NPI number — PATHOLOGY ASSOCIATES OF BOONE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATHOLOGY ASSOCIATES OF BOONE PC
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:
1497718100
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/04/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1867
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLUEFIELD
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
24701-5867
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
336 DEERFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOONE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28607-5008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-262-4100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HALL
Authorized Official First Name:
BRENT
Authorized Official Middle Name:
DWAYE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
828-262-4106

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X , with the licence number:  34026 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 890219F , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com