Basic Information
| Provider Information | |||||||||
| NPI: | 1629016282 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PATHOLOGY ASSOCIATES OF SILVER SPRING, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 856 | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217050856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2403642515 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 FOREST GLEN RD | ||||||||
| Address2: | |||||||||
| City: | SILVER SPRING | ||||||||
| State: | MD | ||||||||
| PostalCode: | 209101483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017547335 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 05/15/2015 | ||||||||
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| AuthorizedOfficialLastName: | MITCHELL | ||||||||
| AuthorizedOfficialFirstName: | J STEPHEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PATHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 2405661600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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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 |
ID Information
| ID | Type | State | Issuer | Description | 143401200 | 05 | MD | MEDICAID |