Provider Demographics
NPI:1033108519
Name:MAWD PATHOLOGY GROUP PA
Entity Type:Organization
Organization Name:MAWD PATHOLOGY GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:W
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-396-8509
Mailing Address - Street 1:9705 LENEXA DR
Mailing Address - Street 2:
Mailing Address - City:LENEXA
Mailing Address - State:KS
Mailing Address - Zip Code:66215-1345
Mailing Address - Country:US
Mailing Address - Phone:913-396-8509
Mailing Address - Fax:913-495-9743
Practice Address - Street 1:9705 LENEXA DR
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66215-1345
Practice Address - Country:US
Practice Address - Phone:913-396-8509
Practice Address - Fax:913-495-9743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO26D0652254207ZP0102X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOC50355OtherMEDICARE - RAILROAD
KS100213310AMedicaid
MO690077079OtherMEDICARE - RAILROAD
MO700717119Medicaid
KS100213310AMedicaid
MO700717119Medicaid
MO9005689IMedicare ID - Type Unspecified
MO9005689GMedicare ID - Type Unspecified
MO9005689JMedicare ID - Type Unspecified
MOC50355OtherMEDICARE - RAILROAD
MO9005689CMedicare ID - Type Unspecified