Basic Information
| Provider Information | |||||||||
| NPI: | 1720041403 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRAND JUNCTION PATHOLOGISTS, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 WELLINGTON AVE | ||||||||
| Address2: | STE 206 | ||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815016131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702438812 | ||||||||
| FaxNumber: | 9702411308 | ||||||||
| Practice Location | |||||||||
| Address1: | 2635 N 7TH ST | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815018209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702442064 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 05/02/2022 | ||||||||
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| AuthorizedOfficialLastName: | LONG | ||||||||
| AuthorizedOfficialFirstName: | AARON | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9702982069 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 05/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | GRD5008 | 01 | BCBS | OTHER | 04019212 | 05 | CO | MEDICAID |