1649427824 NPI number — PATHOLOGY ASSOCIATES OF TYLER PA

Table of content: (NPI 1649427824)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649427824 NPI number — PATHOLOGY ASSOCIATES OF TYLER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PATHOLOGY ASSOCIATES OF TYLER 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:
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:
1649427824
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1726 S BECKHAM AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TYLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75701-4465
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-593-0481
Provider Business Mailing Address Fax Number:
903-592-0555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1726 S BECKHAM AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TYLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75701-4465
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-593-0481
Provider Business Practice Location Address Fax Number:
903-592-0555
Provider Enumeration Date:
08/19/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KULAGA
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
903-593-0481

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: 00HE79 . This is a "BCBS TX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: CP30601 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 110790601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".