Basic Information
| Provider Information | |||||||||
| NPI: | 1700860434 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AMERIPATH LUBBOCK 5.01(A) CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PATHOLOGY ASSOCIATES OF TEXAS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14275 MIDWAY RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 6102714245 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134321100 | ||||||||
| FaxNumber: | 7134320221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 04/12/2022 | ||||||||
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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: | 04/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 45D0701182 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 45D0914073 | 01 | TX | CLIA | OTHER | 121877803 | 05 | TX | MEDICAID | 0T841 | 01 | TX | BCBS | OTHER | 200393940A | 05 | OK | MEDICAID |