Basic Information
| Provider Information | |||||||||
| NPI: | 1831236652 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PATH LAB OF MIDDLE TENNESSEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1069 | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371161069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158681266 | ||||||||
| FaxNumber: | 6158681316 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 N HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | MURFREESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371303837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153964489 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2007 | ||||||||
| LastUpdateDate: | 08/10/2009 | ||||||||
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| AuthorizedOfficialLastName: | MICHAELSON | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | LABORATORY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6153964489 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 25282 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 2006591 | 01 | TN | BLUE CROSS | OTHER | 220015692 | 01 | TN | RAILROAD MEDICARE | OTHER | 3032197 | 05 | TN | MEDICAID | 3083843 | 05 | TN | MEDICAID | 220015757 | 01 | TN | RAILROAD MEDICARE | OTHER | 3049004 | 01 | TN | BLUE CROSS | OTHER |