Basic Information
| Provider Information | |||||||||
| NPI: | 1942278411 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PATHOLOGISTS DIAGNOSTIC SERVICES PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 30369 | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369998888 | ||||||||
| FaxNumber: | 3369998889 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 SILAS CREEK PARKWAY | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367183771 | ||||||||
| FaxNumber: | 3367189259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2006 | ||||||||
| LastUpdateDate: | 11/24/2020 | ||||||||
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| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | CULLEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3367183771 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 11/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZD0900X | 200000967 | NC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology | 207ZH0000X | 22509 | NC | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Hematology | 207ZP0102X | 24810 | NC | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | BCBS | 01 | 01926 | OTHER | 8901926 | 05 | NC | MEDICAID |