Provider Demographics
NPI:1093889347
Name:PATHOLOGY SERVICES LABORATORY PA
Entity Type:Organization
Organization Name:PATHOLOGY SERVICES LABORATORY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:JETTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-968-6781
Mailing Address - Street 1:PO BOX 925
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-0925
Mailing Address - Country:US
Mailing Address - Phone:479-968-6781
Mailing Address - Fax:479-968-3074
Practice Address - Street 1:1430 WEST C STREET
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72811-0925
Practice Address - Country:US
Practice Address - Phone:479-968-6781
Practice Address - Fax:479-968-3074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC0330207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARMC0330OtherLICENSE NUMBER
AR103882709Medicaid
770091902OtherBREASTCARE
AR103882709Medicaid