1396717054 NPI number — AMERIPATH CONSULTING PATHOLOGY SERVICES PA

Table of content: (NPI 1396717054)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396717054 NPI number — AMERIPATH CONSULTING PATHOLOGY SERVICES PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMERIPATH CONSULTING PATHOLOGY SERVICES PA
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:
1396717054
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2560 N. SHADELAND AVENUE
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46219-1706
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-275-8072
Provider Business Mailing Address Fax Number:
317-275-8124

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
568 RUIN CREEK RD
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27536-5921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-492-4477
Provider Business Practice Location Address Fax Number:
252-436-1899
Provider Enumeration Date:
02/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GREENE
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
H
Authorized Official Title or Position:
VP
Authorized Official Telephone Number:
214-932-8270

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  34D0239955 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02332 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 015MV . This is a "BCBS NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 003480461 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1396717054 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7001174 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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