Basic Information
| Provider Information | |||||||||
| NPI: | 1447245881 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PARK PATHOLOGY ASSOCIATES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5620 SOUTHWYCK BLVD | ||||||||
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| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436141501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005941876 | ||||||||
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| Practice Location | |||||||||
| Address1: | 269 PORTLAND WAY S | ||||||||
| Address2: | |||||||||
| City: | GALION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448332312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8005941876 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | PARK | ||||||||
| AuthorizedOfficialFirstName: | JOON | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4194680708 | ||||||||
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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 | 207ZP0102X | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 0690453 | 05 | OH | MEDICAID | 000000163396 | 01 | OH | ANTHEM | OTHER | CF1562 | 01 | RAILROAD MEDICARE | OTHER |