Basic Information
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| NPI: | 1255300810 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PLYMOUTH PATHOLOGY ASSOCIATES, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 275 SANDWICH ST | ||||||||
| Address2: | JORDAN HOSPITAL | ||||||||
| City: | PLYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023602183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088302466 | ||||||||
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| Practice Location | |||||||||
| Address1: | 275 SANDWICH ST | ||||||||
| Address2: | JORDAN HOSPITAL | ||||||||
| City: | PLYMOUTH | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023602183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088302466 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 03/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | BARDAWIL | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5087462000 | ||||||||
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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 | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 9777571 | 05 | MA | MEDICAID |