Basic Information
| Provider Information | |||||||||
| NPI: | 1306875877 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | YALE UNIVERSITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | YALE PATHOLOGY LABS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 GEORGE ST FL 6 | ||||||||
| Address2: | PO BOX 9805 | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065116624 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 310 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065103218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037852788 | ||||||||
| FaxNumber: | 2037856414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 09/26/2008 | ||||||||
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| AuthorizedOfficialLastName: | DESS-SANTORO | ||||||||
| AuthorizedOfficialFirstName: | MARIANNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2037852140 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 004134368 | 05 | CT | MEDICAID |