Basic Information
| Provider Information | |||||||||
| NPI: | 1245302009 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID-ATLANTIC PATHOLOGY SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11025 RCA CENTER DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334104269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616265512 | ||||||||
| FaxNumber: | 5616264530 | ||||||||
| Practice Location | |||||||||
| Address1: | 405 GLENN DR | ||||||||
| Address2: | SUITE 10-A | ||||||||
| City: | STERLING | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201647119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7034048189 | ||||||||
| FaxNumber: | 7034041131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2006 | ||||||||
| LastUpdateDate: | 02/17/2015 | ||||||||
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| AuthorizedOfficialLastName: | GRATTENDICK | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5616265512 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 49D0898222 | VA | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 006601839 | 05 | VA | MEDICAID | 137554 | 01 | VA | SOUTHERN HEALTHCARE | OTHER | 690007157 | 01 | VA | RAILROAD MEDICARE | OTHER | 006601812 | 05 | VA | MEDICAID | 4109007 00 | 05 | MD | MEDICAID | B020 | 01 | VA | CAREFIRST BLUE CROSS DC | OTHER | KU90MI | 01 | VA | CAREFIRST OF MARYLAND | OTHER | 6902000000KU90 | 01 | VA | CAREFIRST NATIONAL ACCTS | OTHER | 200330 | 01 | VA | ANTHEM BLUE CROSS | OTHER |