Basic Information
| Provider Information | |||||||||
| NPI: | 1316442668 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INSTITUTE FOR DERMATOPATHOLOGY, INC. | ||||||||
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| OtherOrganizationName: | AMERIPATH MID ATLANTIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14275 MIDWAY RD STE 400 | ||||||||
| Address2: | |||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149328029 | ||||||||
| FaxNumber: | 6102714245 | ||||||||
| Practice Location | |||||||||
| Address1: | 14225 NEWBROOK DRIVE | ||||||||
| Address2: | 1ST FLOOR, SUITE A | ||||||||
| City: | CHANTILLY | ||||||||
| State: | VA | ||||||||
| PostalCode: | 20151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8337492637 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2018 | ||||||||
| LastUpdateDate: | 05/22/2018 | ||||||||
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| AuthorizedOfficialLastName: | SHERMAN | ||||||||
| AuthorizedOfficialFirstName: | NATHAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7038027081 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERIPATH, INC. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.