Basic Information
| Provider Information | |||||||||
| NPI: | 1497708010 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JEANNETTE DIAGNOSTIC PATHOLOGY INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 157 | ||||||||
| Address2: | |||||||||
| City: | GRAPEVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 15634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7245276517 | ||||||||
| FaxNumber: | 7245276519 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | JEANNETTE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 156440600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7245273551 | ||||||||
| FaxNumber: | 7245276519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BAUTISIA | ||||||||
| AuthorizedOfficialFirstName: | PRIMO | ||||||||
| AuthorizedOfficialMiddleName: | V | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7245276517 | ||||||||
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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 | 207ZP0105X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0019160310002 | 05 | PA | MEDICAID |