Provider Demographics
NPI:1003883877
Name:PATHOLOGISTS DIAGNOSTIC LABORATORY PA
Entity Type:Organization
Organization Name:PATHOLOGISTS DIAGNOSTIC LABORATORY PA
Other - Org Name:ATLANTIC PATHOLOGY SERVICES PA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CULLEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-306-5777
Mailing Address - Street 1:PO BOX 896315
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-0369
Mailing Address - Country:US
Mailing Address - Phone:336-999-8888
Mailing Address - Fax:369-998-8889
Practice Address - Street 1:1800 S HAWTHORNE RD STE 100
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4014
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:2006-03-01
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9300150207ZD0900X
NC22509207ZH0000X
NC22288207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Single Specialty
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC014HEOtherBCBS
SCL00213Medicaid
NC7001277Medicaid
VA010345456Medicaid
NC2576604Medicare PIN
NC014HEOtherBCBS