Basic Information
| Provider Information | |||||||||
| NPI: | 1306916937 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOLIVAR PATHOLOGY SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 98535 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276248535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194207811 | ||||||||
| FaxNumber: | 9194207815 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 E SUNFLOWER RD | ||||||||
| Address2: | 901 HWY 8 EAST | ||||||||
| City: | CLEVELAND | ||||||||
| State: | MS | ||||||||
| PostalCode: | 387322833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6628465689 | ||||||||
| FaxNumber: | 6628462244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 02/04/2011 | ||||||||
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| AuthorizedOfficialLastName: | SPARACINO | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PATHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 6015732307 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 16044 | MS | N | Laboratories | Clinical Medical Laboratory | 171W00000X | 16044 | MS | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Contractor |
No ID Information.