Basic Information
| Provider Information | |||||||||
| NPI: | 1437424975 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PATHOLOGISTS DIAGNOSTIC LABORATORY PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | ATLANTIC PATHOLOGY SERVICES PA | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30369 | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271300369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3699988883 | ||||||||
| FaxNumber: | 3699988889 | ||||||||
| Practice Location | |||||||||
| Address1: | 630 BROOKWOOD BUSINESS PARK DR | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271054478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369998888 | ||||||||
| FaxNumber: | 3369998889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2012 | ||||||||
| LastUpdateDate: | 11/24/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | CARLA | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | CLIENT SERVICES MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3369998888 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 010345456 | 05 | VA | MEDICAID | L00213 | 05 | SC | MEDICAID | 7001277 | 05 | NC | MEDICAID |