Basic Information
| Provider Information | |||||||||
| NPI: | 1003883877 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PATHOLOGISTS DIAGNOSTIC LABORATORY PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ATLANTIC PATHOLOGY SERVICES PA | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30369 | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271300369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369998888 | ||||||||
| FaxNumber: | 3699988889 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 W 4TH ST STE 600 | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271013816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369998888 | ||||||||
| FaxNumber: | 3369998889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2006 | ||||||||
| LastUpdateDate: | 10/03/2022 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | CULLEN | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3363065777 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZD0900X | 9300150 | NC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology | 207ZH0000X | 22509 | NC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Hematology | 207ZP0102X | 22288 | NC | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | L00213 | 05 | SC | MEDICAID | 010345456 | 05 | VA | MEDICAID | 014HE | 01 | NC | BCBS | OTHER | 7001277 | 05 | NC | MEDICAID |