Basic Information
| Provider Information | |||||||||
| NPI: | 1629051842 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIOUXLAND PATHOLOGY GROUP SMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1463 | ||||||||
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| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511021463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122792263 | ||||||||
| FaxNumber: | 7122795631 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 5TH ST | ||||||||
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| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511011394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122792052 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | QALBANI | ||||||||
| AuthorizedOfficialFirstName: | ASKAR | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7122792052 | ||||||||
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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 | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 30266 | 01 | IA | WELLMARK BLUE CROSS | OTHER | 0302661 | 05 | IA | MEDICAID | 31140722800 | 05 | NE | MEDICAID | 0005921 | 01 | SD | WELLMARK BLUE CROSS SD | OTHER |