Basic Information
| Provider Information | |||||||||
| NPI: | 1043324767 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HUB CARE PATHOLOGY, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5052 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394021069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012612587 | ||||||||
| FaxNumber: | 6012613201 | ||||||||
| Practice Location | |||||||||
| Address1: | 5052 W 4TH ST | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394021069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012612587 | ||||||||
| FaxNumber: | 6012613201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 11/02/2020 | ||||||||
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| AuthorizedOfficialLastName: | KRATZ | ||||||||
| AuthorizedOfficialFirstName: | KURT | ||||||||
| AuthorizedOfficialMiddleName: | GREGORY | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6012612587 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 11/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 13985 | MS | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 09014846 | 05 | MS | MEDICAID | 25D0929363 | 01 | MS | CLIA | OTHER | CI2750 | 01 | MS | RAILROAD MEDICARE | OTHER |