1770575623 NPI number — LIBERTY DIAGNOSTIC PATHOLOGY PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770575623 NPI number — LIBERTY DIAGNOSTIC PATHOLOGY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIBERTY DIAGNOSTIC PATHOLOGY 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:
1770575623
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/11/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4567 CROSSROADS PARK DR
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
LIVERPOOL
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13088-3589
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-434-9309
Provider Business Mailing Address Fax Number:
315-454-0136

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
355 GRAND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JERSEY CITY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07302-4321
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-915-2485
Provider Business Practice Location Address Fax Number:
201-915-2377
Provider Enumeration Date:
08/17/2005

Additional Information

Authorized Official

Authorized Official Last Name:
STRAND
Authorized Official First Name:
CALVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
201-915-2485

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: 9027009 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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