Basic Information
| Provider Information | |||||||||
| NPI: | 1568426575 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CYTOLAB PATHOLOGY SERVICES INC PS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100559 | ||||||||
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| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295010559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436644300 | ||||||||
| FaxNumber: | 8436644308 | ||||||||
| Practice Location | |||||||||
| Address1: | 6825 216TH ST SW | ||||||||
| Address2: | |||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980367379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257128020 | ||||||||
| FaxNumber: | 4257128349 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 12/20/2007 | ||||||||
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| AuthorizedOfficialLastName: | NAKONECHNY | ||||||||
| AuthorizedOfficialFirstName: | DONOLD | ||||||||
| AuthorizedOfficialMiddleName: | SAMUEL | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4257128020 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | MD00012785 | WA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0102X | MD00012785 | WA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 12538 | 01 | WA | BCBS | OTHER | 7015084 | 05 | WA | MEDICAID |