Basic Information
Provider Information | |||||||||
NPI: | 1932339967 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INNOVATIVE PATHOLOGY SERVICES LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | EMERGE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 950 | ||||||||
Address2: |   | ||||||||
City: | GOSHEN | ||||||||
State: | NY | ||||||||
PostalCode: | 109240950 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8452944339 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 156 ROUTE 59 | ||||||||
Address2: |   | ||||||||
City: | SUFFERN | ||||||||
State: | NY | ||||||||
PostalCode: | 109013627 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8456153319 | ||||||||
FaxNumber: | 8452944366 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/24/2009 | ||||||||
LastUpdateDate: | 01/13/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NEWMAN | ||||||||
AuthorizedOfficialFirstName: | SCHUYLER | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8453427156 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X |   |   | Y |   | Laboratories | Clinical Medical Laboratory |   |
No ID Information.