Basic Information
| Provider Information | |||||||||
| NPI: | 1962423814 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CROWN PATHOLOGY, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1820 | ||||||||
| Address2: | |||||||||
| City: | PRESQUE ISLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047691820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077647529 | ||||||||
| FaxNumber: | 2077646504 | ||||||||
| Practice Location | |||||||||
| Address1: | 140 ACADEMY ST | ||||||||
| Address2: | |||||||||
| City: | PRESQUE ISLE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 047693102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077684209 | ||||||||
| FaxNumber: | 2077684013 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2006 | ||||||||
| LastUpdateDate: | 09/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | CARSON | ||||||||
| AuthorizedOfficialFirstName: | PAULA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING AGENT | ||||||||
| AuthorizedOfficialTelephone: | 2077647529 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0105X | 012546 | ME | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
ID Information
| ID | Type | State | Issuer | Description | 9482121 | 01 | ME | CIGNA GROUP # | OTHER | 003962 | 01 | ME | ANTHEM | OTHER | 220016505 | 01 | ME | RAILROAD MEDICARE GROUP # | OTHER | 123680000 | 05 | ME | MEDICAID |