Basic Information
| Provider Information | |||||||||
| NPI: | 1215990148 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID AMERICA PATHOLOGY LABORATORY LLC | ||||||||
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| OtherOrganizationName: | MIDWEST ANATOMIC PATHOLOGY LABORATORY LLC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 52990 | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296490048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642233600 | ||||||||
| FaxNumber: | 8642236054 | ||||||||
| Practice Location | |||||||||
| Address1: | 7301 COLLEGE BLVD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662101937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133416297 | ||||||||
| FaxNumber: | 9133416299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 10/26/2012 | ||||||||
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| AuthorizedOfficialLastName: | BENSON | ||||||||
| AuthorizedOfficialFirstName: | RUSSELL | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9133416297 | ||||||||
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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 | 291U00000X | KS | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 100364660A | 05 | KS | MEDICAID | 704970607 | 05 | MO | MEDICAID | 33818014 | 01 | MO | KANSAS CITY BCBS | OTHER | 405042 | 01 | KS | BCBS | OTHER |