Basic Information
Provider Information | |||||||||
NPI: | 1457508400 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AMERIPATH TUCSON, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | JILL A COHEN MD INC | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 14275 MIDWAY DRIVE | ||||||||
Address2: | SUITE 400 | ||||||||
City: | ADDISON | ||||||||
State: | TX | ||||||||
PostalCode: | 750013676 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5203207681 | ||||||||
FaxNumber: | 6102714245 | ||||||||
Practice Location | |||||||||
Address1: | 7485 E TANQUE VERDE RD | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857153477 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5203207681 | ||||||||
FaxNumber: | 5203207684 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/21/2008 | ||||||||
LastUpdateDate: | 03/17/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KRAMER | ||||||||
AuthorizedOfficialFirstName: | EDWARD | ||||||||
AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6105503003 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | AMERIPATH INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZD0900X | 03D0980494 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology |
ID Information
ID | Type | State | Issuer | Description | 03D0980494 | 01 | AZ | CLIA | OTHER |