Basic Information
Provider Information | |||||||||
NPI: | 1720118714 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LAKELAND PATHOLOGY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1200 E 25TH STREET | ||||||||
Address2: |   | ||||||||
City: | HIBBING | ||||||||
State: | MN | ||||||||
PostalCode: | 557462341 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2183123002 | ||||||||
FaxNumber: | 2183123003 | ||||||||
Practice Location | |||||||||
Address1: | 750 E 34TH ST | ||||||||
Address2: |   | ||||||||
City: | HIBBING | ||||||||
State: | MN | ||||||||
PostalCode: | 557462341 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2183123002 | ||||||||
FaxNumber: | 2183123003 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/07/2007 | ||||||||
LastUpdateDate: | 10/20/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | UNCINI | ||||||||
AuthorizedOfficialFirstName: | THOMAS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 2183123002 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 29005 | MN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
ID | Type | State | Issuer | Description | 14784LA | 01 | MN | BLUE CROSS BLUE SHIELD | OTHER | CS4970 | 01 | MN | RAILROAD MEDICARE | OTHER | 979273200 | 05 | MN |   | MEDICAID |