Basic Information
| Provider Information | |||||||||
| NPI: | 1235266750 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHERIDAN PATHOLOGY ASSOCIATES PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 807 | ||||||||
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| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828010807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076737164 | ||||||||
| FaxNumber: | 3076746887 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 W 5TH ST | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828012705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076737164 | ||||||||
| FaxNumber: | 3076746887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 01/21/2010 | ||||||||
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| AuthorizedOfficialLastName: | DOUGHTY | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | EDWARD | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3076721042 | ||||||||
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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 | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 106378200 | 05 | WY | MEDICAID |