Basic Information
| Provider Information | |||||||||
| NPI: | 1194797993 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMERIPATH NEW YORK LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AMERIPATH NORTHEAST | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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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: | 1 GREENWICH PL | ||||||||
| Address2: | |||||||||
| City: | SHELTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064844618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8664369631 | ||||||||
| FaxNumber: | 2034478666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 04/24/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KRAMER | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6105503000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERIPATH INC. | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 07D1035411 | NY | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 004250130 | 05 | CT | MEDICAID | 200279840A | 05 | OK | MEDICAID | 100771649003 | 05 | PA | MEDICAID | 7001262 | 05 | NC | MEDICAID | 176325201 | 05 | TX | MEDICAID | 3810005215 | 05 | WV | MEDICAID | 015532634A | 05 | GA | MEDICAID | 22339752 | 05 | CO | MEDICAID | 412163500 | 05 | MD | MEDICAID | L00237 | 05 | SC | MEDICAID | 0093254 | 05 | NJ | MEDICAID | 2643769 | 05 | OH | MEDICAID |