Provider Demographics
NPI:1093843450
Name:PATHOLOGY GROUP OF LOUISIANA, A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:PATHOLOGY GROUP OF LOUISIANA, A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JANNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:DIETEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-706-0513
Mailing Address - Street 1:PO BOX 84030
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70884-4030
Mailing Address - Country:US
Mailing Address - Phone:225-766-4999
Mailing Address - Fax:225-763-5870
Practice Address - Street 1:5339 O'DONOVAN DRIVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808
Practice Address - Country:US
Practice Address - Phone:225-766-4999
Practice Address - Fax:225-763-5870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No207ZB0001XAllopathic & Osteopathic PhysiciansPathologyBlood Banking & Transfusion MedicineGroup - Single Specialty
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Single Specialty
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Single Specialty
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematologyGroup - Single Specialty
No207ZI0100XAllopathic & Osteopathic PhysiciansPathologyImmunopathologyGroup - Single Specialty
No207ZM0300XAllopathic & Osteopathic PhysiciansPathologyMedical MicrobiologyGroup - Single Specialty
No207ZN0500XAllopathic & Osteopathic PhysiciansPathologyNeuropathologyGroup - Single Specialty
No207ZP0007XAllopathic & Osteopathic PhysiciansPathologyMolecular Genetic PathologyGroup - Single Specialty
No207ZP0213XAllopathic & Osteopathic PhysiciansPathologyPediatric PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1184781Medicaid
LA1184781Medicaid