Provider Demographics
NPI:1073648069
Name:SKIN PATHOLOGY LABORATORY, INC.
Entity Type:Organization
Organization Name:SKIN PATHOLOGY LABORATORY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAG
Authorized Official - Middle Name:
Authorized Official - Last Name:BHAWAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-638-5570
Mailing Address - Street 1:680 WORCESTER RD
Mailing Address - Street 2:
Mailing Address - City:FRAMINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01702-5259
Mailing Address - Country:US
Mailing Address - Phone:508-620-2800
Mailing Address - Fax:508-620-2808
Practice Address - Street 1:609 ALBANY ST FL 3
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2515
Practice Address - Country:US
Practice Address - Phone:617-638-5570
Practice Address - Fax:617-638-5575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9750878Medicaid
MA9750878Medicaid