Provider Demographics
NPI:1073650610
Name:WESTERN WASHINGTON PATHOLOGY PS
Entity Type:Organization
Organization Name:WESTERN WASHINGTON PATHOLOGY PS
Other - Org Name:PATHOLOGY ASSOCIATES OF TACOMA PS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:ROB
Authorized Official - Middle Name:ROY
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-403-1043
Mailing Address - Street 1:315 MARTIN LUTHER KING JR WAY
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4234
Mailing Address - Country:US
Mailing Address - Phone:253-403-1043
Mailing Address - Fax:253-403-1357
Practice Address - Street 1:315 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4234
Practice Address - Country:US
Practice Address - Phone:253-403-1043
Practice Address - Fax:253-403-1357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601053749207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA50D0718142OtherCLIA
WAMTS2713OtherWASH MEDICAL TEST SITE
WA7020142Medicaid
WACO4260Medicare PIN
WA50D0718142OtherCLIA
WAMTS2713OtherWASH MEDICAL TEST SITE