Basic Information
| Provider Information | |||||||||
| NPI: | 1285797571 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST LUKES PATHOLOGY ASSOCIATES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7111 FAIRWAY DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | PALM BEACH GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334184207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617126265 | ||||||||
| FaxNumber: | 5617127349 | ||||||||
| Practice Location | |||||||||
| Address1: | 12300 METCALF AVE | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662131324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8169323241 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 12/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | GREENE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 2149328270 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERIPATH INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 17D1034613 | KS | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 501949507A | 05 | KS | MEDICAID | 1285797571 | 05 | MO | MEDICAID |