Basic Information
| Provider Information | |||||||||
| NPI: | 1104898873 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DERMATOPATHOLOGY SERVICES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14275 MIDWAY RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149328029 | ||||||||
| FaxNumber: | 6102714245 | ||||||||
| Practice Location | |||||||||
| Address1: | 3918 MONTCLAIR RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352132417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2058704897 | ||||||||
| FaxNumber: | 2058714709 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 04/24/2015 | ||||||||
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| AuthorizedOfficialLastName: | KRAMER | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6105503000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERIPATH INC. | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 01D0641513 | AL | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 1507087 | 05 | TN | MEDICAID | 56306 | 01 | AL | BCBS | OTHER | 7001200 | 05 | NC | MEDICAID | 000056306 | 05 | AL | MEDICAID | 03884230 | 05 | MS | MEDICAID | 547254876A | 05 | GA | MEDICAID | 1015385 | 05 | LA | MEDICAID |