Basic Information
| Provider Information | |||||||||
| NPI: | 1124441431 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MPATH, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MATTOCH PATHOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7268 | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805370268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706632742 | ||||||||
| FaxNumber: | 9706990159 | ||||||||
| Practice Location | |||||||||
| Address1: | 1708 BOISE AVE | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805384204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708186788 | ||||||||
| FaxNumber: | 9703724699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2014 | ||||||||
| LastUpdateDate: | 02/08/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | MATTOCH | ||||||||
| AuthorizedOfficialFirstName: | INGERLISA | ||||||||
| AuthorizedOfficialMiddleName: | WENCHE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9708186788 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0101X | 49136 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology |
No ID Information.