Basic Information
| Provider Information | |||||||||
| NPI: | 1750580510 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PARKWAY PATHOLOGY GROUP | ||||||||
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| OtherOrganizationName: | PARKWAY PATHOLOGY MO BAP SULLIVAN | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 500720 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631500720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149890300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 751 SAPPINGTON BRIDGE RD | ||||||||
| Address2: | ATTN: PATHOLOGY DEPARTMENT | ||||||||
| City: | SULLIVAN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630802354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734684186 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2007 | ||||||||
| LastUpdateDate: | 10/22/2007 | ||||||||
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| AuthorizedOfficialLastName: | SHORT | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3149964285 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PARKWAY PATHOLOGY GROUP | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0102X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.