Basic Information
| Provider Information | |||||||||
| NPI: | 1982609640 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AFFILIATES IN PATHOLOGY SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 FOUNTAIN AVE | ||||||||
| Address2: | STE 300 | ||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420012771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704429519 | ||||||||
| FaxNumber: | 3146314491 | ||||||||
| Practice Location | |||||||||
| Address1: | 1530 LONE OAK RD | ||||||||
| Address2: | |||||||||
| City: | PADUCAH | ||||||||
| State: | KY | ||||||||
| PostalCode: | 420037901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704429519 | ||||||||
| FaxNumber: | 3146314491 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | SPREI | ||||||||
| AuthorizedOfficialFirstName: | STANLEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 2704429519 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | KY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 000000317622 | 01 | KY | BCBS KY PIN | OTHER | DC1348 | 01 | KY | MEDICARE RAILROAD | OTHER |