1306837737 NPI number — THE PATHOLOGY GROUP PC

Table of content: (NPI 1306837737)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306837737 NPI number — THE PATHOLOGY GROUP PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE PATHOLOGY GROUP PC
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:
1306837737
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4235
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND JUNCTION
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-256-6463
Provider Business Mailing Address Fax Number:
970-549-4140

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2351 G ROAD
Provider Second Line Business Practice Location Address:
COMMUNITY HOSPITAL
Provider Business Practice Location Address City Name:
GRAND JUNCTION
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-549-4140
Provider Business Practice Location Address Fax Number:
432-223-2147
Provider Enumeration Date:
11/03/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HAVLIK
Authorized Official First Name:
DEAN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
970-256-6266

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: CI3527 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 04023412 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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