Basic Information
| Provider Information | |||||||||
| NPI: | 1841234184 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | YAVAPAI PATHOLOGY ASSOCIATES PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 20490 | ||||||||
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| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852770490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809851093 | ||||||||
| FaxNumber: | 4809850468 | ||||||||
| Practice Location | |||||||||
| Address1: | 1003 WILLOW CREEK RD | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863011641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809851093 | ||||||||
| FaxNumber: | 4809850468 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 10/02/2007 | ||||||||
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| AuthorizedOfficialLastName: | GALLO | ||||||||
| AuthorizedOfficialFirstName: | ROEL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4809851093 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0101X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology |
ID Information
| ID | Type | State | Issuer | Description | CB2931 | 01 | RAIL ROAD MEDICARE GROUP | OTHER |