1104898873 NPI number — DERMATOPATHOLOGY SERVICES INC

Table of content: (NPI 1104898873)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104898873 NPI number — DERMATOPATHOLOGY SERVICES INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMATOPATHOLOGY SERVICES INC
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:
1104898873
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14275 MIDWAY RD
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
ADDISON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75001-3614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-932-8029
Provider Business Mailing Address Fax Number:
610-271-4245

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3918 MONTCLAIR RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
BIRMINGHAM
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35213-2417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-870-4897
Provider Business Practice Location Address Fax Number:
205-871-4709
Provider Enumeration Date:
02/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KRAMER
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
M
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
610-550-3000

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  01D0641513 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1507087 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 56306 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 7001200 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000056306 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 03884230 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 547254876A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1015385 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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