Basic Information
| Provider Information | |||||||||
| NPI: | 1881666568 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BURROW PATHOLOGY LABORATORIES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30309 | ||||||||
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| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294170309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435549300 | ||||||||
| FaxNumber: | 8435668780 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 RAWLS DR | ||||||||
| Address2: | |||||||||
| City: | MCCOMB | ||||||||
| State: | MS | ||||||||
| PostalCode: | 396482833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016840465 | ||||||||
| FaxNumber: | 6016843031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 07/09/2010 | ||||||||
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| AuthorizedOfficialLastName: | WILLIS | ||||||||
| AuthorizedOfficialFirstName: | TURNER | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6016840465 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZB0001X | 12940 | MS | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Blood Banking & Transfusion Medicine | 207ZP0102X | 12940 | MS | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 291U00000X | MS | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 1938637 | 05 | LA | MEDICAID | 00123769 | 05 | MS | MEDICAID |