Basic Information
| Provider Information | |||||||||
| NPI: | 1174503999 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PATHOLOGY SPECIALIST OF ARIZONA, LLP | ||||||||
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| OtherOrganizationName: | PATHOLOGY SPECIALISTS OF ARIZONA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 42210 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850802210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238897403 | ||||||||
| FaxNumber: | 6238897407 | ||||||||
| Practice Location | |||||||||
| Address1: | 424 S 56TH ST STE 120 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850342177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026855166 | ||||||||
| FaxNumber: | 6026855325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2006 | ||||||||
| LastUpdateDate: | 08/18/2020 | ||||||||
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| AuthorizedOfficialLastName: | DEZORZI | ||||||||
| AuthorizedOfficialFirstName: | ANTOINETTE | ||||||||
| AuthorizedOfficialMiddleName: | LYNNE | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6026855166 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 08/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 647696 | 05 | AZ | MEDICAID |