Basic Information
| Provider Information | |||||||||
| NPI: | 1043294143 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KOKOMO PATHOLOGIST ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6908 | ||||||||
| Address2: | |||||||||
| City: | KOKOMO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469046908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148218055 | ||||||||
| FaxNumber: | 3148211833 | ||||||||
| Practice Location | |||||||||
| Address1: | 1907 W SYCAMORE ST | ||||||||
| Address2: | |||||||||
| City: | KOKOMO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469014113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654565729 | ||||||||
| FaxNumber: | 7654565014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HUGHES | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF LABORATORY | ||||||||
| AuthorizedOfficialTelephone: | 7654565729 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | IN | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | IN0006461 | 01 | IN | TRICARE | OTHER | CB2274 | 01 | IN | TRAVELERS | OTHER | 000000083512 | 01 | IN | BCBS | OTHER | 000000003339 | 01 | IN | MPLAN | OTHER |