Basic Information
| Provider Information | |||||||||
| NPI: | 1295970580 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMERIPATH TEXAS, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AMERIPATH TEXAS, LP | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14275 MIDWAY RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 6102714245 | ||||||||
| Practice Location | |||||||||
| Address1: | 3409 N HIGHWAY 1417 | ||||||||
| Address2: | |||||||||
| City: | SHERMAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750926634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9034631004 | ||||||||
| FaxNumber: | 9034634545 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2008 | ||||||||
| LastUpdateDate: | 10/17/2016 | ||||||||
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| AuthorizedOfficialLastName: | KRAMER | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6105503003 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERIPATH INC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 45D0982307 | TX | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 100759140C | 05 | OK | MEDICAID | 45D0982307 | 01 | TX | CLIA | OTHER | 203143701 | 05 | TX | MEDICAID |