Basic Information
| Provider Information | |||||||||
| NPI: | 1598194821 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UPSTATE EMPIRE PATHOLOGY PLLC | ||||||||
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| Address1: | PO BOX 1818 | ||||||||
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| City: | LATHAM | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121100119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187861296 | ||||||||
| FaxNumber: | 5187861293 | ||||||||
| Practice Location | |||||||||
| Address1: | 2215 BURDETT AVE | ||||||||
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| City: | TROY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121802466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5182713229 | ||||||||
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| ProviderEnumerationDate: | 11/07/2013 | ||||||||
| LastUpdateDate: | 11/07/2013 | ||||||||
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| AuthorizedOfficialLastName: | ELDEIRY | ||||||||
| AuthorizedOfficialFirstName: | DALIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 5187861296 | ||||||||
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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 | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.