Basic Information
Provider Information | |||||||||
NPI: | 1619141306 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INNOVATIVE PATHOLOGY SERVICES PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 60820 | ||||||||
Address2: |   | ||||||||
City: | NORTH CHARLESTON | ||||||||
State: | SC | ||||||||
PostalCode: | 294190820 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8435549300 | ||||||||
FaxNumber: | 8435668780 | ||||||||
Practice Location | |||||||||
Address1: | 501 19TH ST | ||||||||
Address2: | SUITE 301 | ||||||||
City: | KNOXVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 379161854 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8655227591 | ||||||||
FaxNumber: | 8655462618 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/15/2008 | ||||||||
LastUpdateDate: | 04/22/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BEUERLEIN | ||||||||
AuthorizedOfficialFirstName: | FRANK | ||||||||
AuthorizedOfficialMiddleName: | JOSEPH | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8655227591 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZD0900X |   |   | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology | 207ZP0102X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.