Basic Information
| Provider Information | |||||||||
| NPI: | 1821060641 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INSTITUTE FOR DERMATOPATHOLOGY, INC. | ||||||||
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| OtherOrganizationName: | AMERIPATH PITTSBURGH, PC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14275 MIDWAY RD STE 400 | ||||||||
| Address2: | |||||||||
| City: | ADDISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750013676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 6102714245 | ||||||||
| Practice Location | |||||||||
| Address1: | 875 GREENTREE ROAD, SUITE 325 | ||||||||
| Address2: | FOUR PARKWAY CENTER | ||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 15220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008453573 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 08/29/2018 | ||||||||
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| AuthorizedOfficialLastName: | KRAMER | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT/AUTHORIZE OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6105503003 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMERIPATH INC. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 39D0177150 | PA | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 6701101000 | 05 | WV | MEDICAID | 01016391 | 05 | VA | MEDICAID | 1007508900001 | 05 | PA | MEDICAID | 2335262 | 05 | OH | MEDICAID | 1007508900004 | 05 | PA | MEDICAID | 308055 | 01 | PA | BCBS | OTHER |