1275589624 NPI number — DERMATOPATH LAB, INC.

Table of content: (NPI 1275589624)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275589624 NPI number — DERMATOPATH LAB, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMATOPATH LAB, 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:
1275589624
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/05/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
555 PLEASANT ST
Provider Second Line Business Mailing Address:
SUITE 106
Provider Business Mailing Address City Name:
ATTLEBORO
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02703-2400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-226-5540
Provider Business Mailing Address Fax Number:
508-226-9619

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 PLEASANT ST
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
ATTLEBORO
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02703-2400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-226-5540
Provider Business Practice Location Address Fax Number:
508-226-9619
Provider Enumeration Date:
05/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HINES
Authorized Official First Name:
YVONNE
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
508-226-5540

Provider Taxonomy Codes

  • Taxonomy code: 207ND0900X , with the licence number:  2413 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1847-0 . This is a "BCBS" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 350062 . This is a "UHC" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: C028629 . This is a "CHAMPUS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0805548 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9418065 , issued by the state of ( RI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 228418 . This is a "BCBS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 607206 . This is a "TUFTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 0013986 . This is a "NHP" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 1171 . This is a "NHP" identifier , issued by the state of ( RI ) . This identifiers is of the category "OTHER".
  • Identifier: 4754 MIR . This is a "HARVARD/PILGRIM" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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