Provider Demographics
NPI:1043308810
Name:SANTA FE PATHOLOGY SERVICES PA
Entity Type:Organization
Organization Name:SANTA FE PATHOLOGY SERVICES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:CLARK
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:505-820-5399
Mailing Address - Street 1:465 ST MICHAELS DRIVE
Mailing Address - Street 2:SUITE 115
Mailing Address - City:SANTA FE
Mailing Address - State:NJ
Mailing Address - Zip Code:87505-7621
Mailing Address - Country:US
Mailing Address - Phone:505-986-8620
Mailing Address - Fax:505-820-2461
Practice Address - Street 1:455 ST MICHAELS DRIVE
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7621
Practice Address - Country:US
Practice Address - Phone:505-986-8620
Practice Address - Fax:505-820-2461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM207ZP0102X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00051984Medicaid
NM=========OtherCIGNA
NM=========OtherPRESBYTERIAN HEALTH PLAN
NM=========OtherBLUE CROSS & BLUE SHIELD
NM=========OtherLOVELACE HEALTH PLAN
NM00051984Medicaid
NM=========OtherBLUE CROSS & BLUE SHIELD
NM00051984Medicaid
NM=========OtherUNITED HEALTHCARE