Provider Demographics
NPI:1437424975
Name:PATHOLOGISTS DIAGNOSTIC LABORATORY PA
Entity type:Organization
Organization Name:PATHOLOGISTS DIAGNOSTIC LABORATORY PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLIENT SERVICES MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:N
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-999-8888
Mailing Address - Street 1:PO BOX 30369
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27130-0369
Mailing Address - Country:US
Mailing Address - Phone:369-998-8883
Mailing Address - Fax:369-998-8889
Practice Address - Street 1:630 BROOKWOOD BUSINESS PARK DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-4478
Practice Address - Country:US
Practice Address - Phone:336-999-8888
Practice Address - Fax:336-999-8889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-16
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010345456Medicaid
SCL00213Medicaid
NC7001277Medicaid
NC2576604Medicare PIN
VA010345456Medicaid