Basic Information
| Provider Information | |||||||||
| NPI: | 1578535456 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AMERIPATH CLEVELAND INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14275 MIDWAY RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003317546 | ||||||||
| FaxNumber: | 6102714245 | ||||||||
| Practice Location | |||||||||
| Address1: | 7730 FIRST PL | ||||||||
| Address2: | SUITE A | ||||||||
| City: | OAKWOOD VILLAGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441466719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003317546 | ||||||||
| FaxNumber: | 4407032155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 04/10/2022 | ||||||||
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| AuthorizedOfficialLastName: | DOLAN | ||||||||
| AuthorizedOfficialFirstName: | KRISTIE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8666978378 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERIPATH INC. | ||||||||
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| NPICertificationDate: | 04/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 36D0656067 | OH | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 000000024771 | 01 | OH | BCBS | OTHER | 1718561 | 05 | TX | MEDICAID | 101272607 | 05 | PA | MEDICAID | 90386574 | 05 | CO | MEDICAID | 1578535456 | 05 | VA | MEDICAID | 158988709 | 05 | AK | MEDICAID | 084918 | 05 | AZ | MEDICAID | 690031091 | 01 | OH | MC RR | OTHER | 0318525 | 05 | OH | MEDICAID | 4104722 | 05 | MD | MEDICAID | 164729542 | 05 | MI | MEDICAID | 36201300 | 05 | WI | MEDICAID | 7001332 | 05 | NC | MEDICAID | L00234 | 05 | SC | MEDICAID |