Basic Information
| Provider Information | |||||||||
| NPI: | 1336161355 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HAZLETON PATHOLOGY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1388 | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5702888881 | ||||||||
| FaxNumber: | 5702888065 | ||||||||
| Practice Location | |||||||||
| Address1: | 148 N SHERMAN COURT | ||||||||
| Address2: | |||||||||
| City: | HAZLETON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 182015863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5704546301 | ||||||||
| FaxNumber: | 5704546815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 08/06/2015 | ||||||||
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| AuthorizedOfficialLastName: | NULL | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5704546301 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 635079 | 01 | PA | BLUE SHIELD | OTHER | 0012214720008 | 05 | PA | MEDICAID |