Basic Information
| Provider Information | |||||||||
| NPI: | 1538131362 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INSTITUTE FOR DERMATOPATHOLOGY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14275 MIDWAY RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2149328029 | ||||||||
| FaxNumber: | 6102714245 | ||||||||
| Practice Location | |||||||||
| Address1: | 3805 W CHESTER PIKE | ||||||||
| Address2: | BLDG D, STE. 120 | ||||||||
| City: | NEWTOWN SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190732304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102600555 | ||||||||
| FaxNumber: | 6102600566 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 08/06/2014 | ||||||||
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| AuthorizedOfficialLastName: | KRAMER | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 6105503000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERIPATH INC. | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 39D0698461 | PA | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 1000033856 | 05 | DE | MEDICAID | 0363685 | 05 | DC | MEDICAID | 1007734650023 | 05 | PA | MEDICAID | 4180127 00 | 05 | MD | MEDICAID | 8530106 | 05 | NJ | MEDICAID | 353193 | 01 | PA | BCBS | OTHER |