1063619922 NPI number — MATTISON PATHOLOGY, L.L.P.

Table of content: (NPI 1063619922)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063619922 NPI number — MATTISON PATHOLOGY, L.L.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MATTISON PATHOLOGY, L.L.P.
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:
6
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:
1063619922
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3560 MERIDIAN ST STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELLINGHAM
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98225-1731
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-734-2800
Provider Business Mailing Address Fax Number:
360-734-3818

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4245 N CENTRAL EXPY STE 420
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75205-4566
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-987-7284
Provider Business Practice Location Address Fax Number:
469-232-9927
Provider Enumeration Date:
07/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WOLGAMOT
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
866-987-7284

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZC0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 45D1065927 . This is a "CLIA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 7187034 . This is a "COLLEGE OF AMERICAN PATHOLOGISTS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 45D1015603 . This is a "CLIA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 7201511 . This is a "COLLEGE OF AMERICAN PATHOLOGISTS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00Z224 . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 45D1069527 . This is a "CLIA #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 003150500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com