Basic Information
| Provider Information | |||||||||
| NPI: | 1174925382 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ELL PATHOLOGY LAB, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10810 EXECUTIVE CENTER DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722114386 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016042695 | ||||||||
| FaxNumber: | 5016042699 | ||||||||
| Practice Location | |||||||||
| Address1: | 10810 EXECUTIVE CENTER DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722114386 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016042695 | ||||||||
| FaxNumber: | 5016042699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2014 | ||||||||
| LastUpdateDate: | 05/22/2015 | ||||||||
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| AuthorizedOfficialLastName: | WALKER | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER & DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5016042695 | ||||||||
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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 | 207ZP0102X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 04D2068199 | 01 | AR | CLIA | OTHER | LAP80759 | 01 | AR | NYSDOH CLINICAL LABORATORY PERMIT | OTHER |