Provider Demographics
NPI:1043319742
Name:PEDIATRIC PATHOLOGY ASSOCIATES
Entity Type:Organization
Organization Name:PEDIATRIC PATHOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIVISION HEAD-PEDIATRIC PATHOLOGY
Authorized Official - Prefix:DR
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:M
Authorized Official - Last Name:COFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-588-3165
Mailing Address - Street 1:100 N MEDICAL DR
Mailing Address - Street 2:PEDIATRIC PATHOLOGY
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84113-1103
Mailing Address - Country:US
Mailing Address - Phone:801-588-3165
Mailing Address - Fax:801-588-3169
Practice Address - Street 1:100 N MEDICAL DR
Practice Address - Street 2:PATHOLOGY
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84113-1103
Practice Address - Country:US
Practice Address - Phone:801-588-3165
Practice Address - Fax:801-588-3169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0213XAllopathic & Osteopathic PhysiciansPathologyPediatric PathologyGroup - Multi-Specialty
No207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion MedicineGroup - Multi-Specialty
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Multi-Specialty
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Multi-Specialty
No207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic PathologyGroup - Multi-Specialty
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematologyGroup - Multi-Specialty
No207ZI0100XAllopathic & Osteopathic PhysiciansPathologyImmunopathologyGroup - Multi-Specialty
No207ZM0300XAllopathic & Osteopathic PhysiciansPathologyMedical MicrobiologyGroup - Multi-Specialty
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic PathologyGroup - Multi-Specialty
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No207ZP0104XAllopathic & Osteopathic PhysiciansPathologyChemical PathologyGroup - Multi-Specialty
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807250500Medicaid
NV100502354Medicaid
WY118430000Medicaid
UT=========000Medicaid
WY118430000Medicaid