Basic Information
| Provider Information | |||||||||
| NPI: | 1720056294 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRILLIUM PATHOLOGY, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5127 | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458025127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668752536 | ||||||||
| FaxNumber: | 4192232726 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 455042687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375235182 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2006 | ||||||||
| LastUpdateDate: | 08/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | PARAMESWARAN | ||||||||
| AuthorizedOfficialFirstName: | LAKSHMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9375235463 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/20/2020 | ||||||||
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 | 2553160 | 05 | OH | MEDICAID |