Basic Information
| Provider Information | |||||||||
| NPI: | 1750366993 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANDERSON PATHOLOGISTS INC. PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4095 RELIABLE PARKWAY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606860040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148218055 | ||||||||
| FaxNumber: | 3148211833 | ||||||||
| Practice Location | |||||||||
| Address1: | 2015 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460164337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656468433 | ||||||||
| FaxNumber: | 7656832528 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2005 | ||||||||
| LastUpdateDate: | 03/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | ELLIS | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7656468433 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | IN | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | CB8100 | 01 | TRAVELERS | OTHER | 000000085495 | 01 | IN | BCBS | OTHER |