1588764955 NPI number — PINEYWOODS PATHOLOGY PA

Table of content: (NPI 1588764955)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588764955 NPI number — PINEYWOODS PATHOLOGY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINEYWOODS PATHOLOGY PA
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:
RAUL M GUTIERREZ MD PA
Provider Other Organization Name Type Code:
4
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:
1588764955
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO DRAWER 1906
Provider Second Line Business Mailing Address:
821 W FRANK AVE
Provider Business Mailing Address City Name:
LUFKIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75902-1906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-639-5474
Provider Business Mailing Address Fax Number:
936-639-5487

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 W FRANK
Provider Second Line Business Practice Location Address:
MEMORIAL MEDICAL CENTER
Provider Business Practice Location Address City Name:
LUFKIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-639-7886
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TODD
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PROVIDER PRESIDENT
Authorized Official Telephone Number:
936-639-7886

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: 1679557-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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