Basic Information
| Provider Information | |||||||||
| NPI: | 1447324025 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMERIPATH LUBBOCK 5.01(A) CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14275 MIDWAY RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179606225 | ||||||||
| FaxNumber: | 6102714245 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 W RANDOL MILL RD | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | ARLINGTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760122504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179606225 | ||||||||
| FaxNumber: | 8179606519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 04/12/2022 | ||||||||
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| AuthorizedOfficialLastName: | DOLAN | ||||||||
| AuthorizedOfficialFirstName: | KRISTIE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8666978378 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERIPATH INC. | ||||||||
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| NPICertificationDate: | 04/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 45D0484493 | TX | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | CK2772 | 01 | TX | RR MEDICARE | OTHER | CL0302 | 01 | TX | BCBS | OTHER | 200048101 | 05 | TX | MEDICAID | 45D0484493 | 01 | TX | CLIA | OTHER |