Provider Demographics
NPI:1093712689
Name:REDDING PATHOLOGISTS
Entity Type:Organization
Organization Name:REDDING PATHOLOGISTS
Other - Org Name:SHASTA PATHOLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIKOES
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLANKENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-255-1000
Mailing Address - Street 1:PO BOX 994047
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96099-4047
Mailing Address - Country:US
Mailing Address - Phone:530-255-1000
Mailing Address - Fax:530-247-8259
Practice Address - Street 1:2036 RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-1801
Practice Address - Country:US
Practice Address - Phone:530-255-1000
Practice Address - Fax:530-247-8259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-28
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF00011395207ZP0102X
CACLF11395291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ58543ZMedicaid
CAE71334Medicare UPIN
CAH97770Medicare UPIN
CAA50541Medicare UPIN
CAF18637Medicare UPIN
CAZZZ23957ZMedicare ID - Type Unspecified
CAE75699Medicare UPIN