1093704629 NPI number — EL PASO PATHOLOGY LABORATORY

Table of content: (NPI 1093704629)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093704629 NPI number — EL PASO PATHOLOGY LABORATORY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EL PASO PATHOLOGY LABORATORY
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:
1093704629
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:
1201 E SCHUSTER AVE
Provider Second Line Business Mailing Address:
4B
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79902-4672
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
915-533-1300
Provider Business Mailing Address Fax Number:
915-533-1309

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 E SCHUSTER AVE
Provider Second Line Business Practice Location Address:
4B
Provider Business Practice Location Address City Name:
EL PASO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79902-4672
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-533-1300
Provider Business Practice Location Address Fax Number:
915-533-1300
Provider Enumeration Date:
10/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MCGEE
Authorized Official First Name:
WM
Authorized Official Middle Name:
GORDON
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
915-533-1300

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1677932 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 77323815 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: CL5126 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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