Basic Information
| Provider Information | |||||||||
| NPI: | 1821028689 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ONTARIO PATHOLOGY GROUP, LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9589 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837074589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084728120 | ||||||||
| FaxNumber: | 2083441926 | ||||||||
| Practice Location | |||||||||
| Address1: | 351 S.W. NINTH ST. | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418815331 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 08/26/2007 | ||||||||
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| AuthorizedOfficialLastName: | RYSENGA | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
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| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 5418815331 | ||||||||
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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 | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 287920 | 05 | OR | MEDICAID |