Provider Demographics
NPI:1114996667
Name:TAACH PATHOLOGY, LTD
Entity Type:Organization
Organization Name:TAACH PATHOLOGY, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:KHACHATURIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-922-4923
Mailing Address - Street 1:6501 E. GREENWAY PKWY.
Mailing Address - Street 2:#103-447
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254
Mailing Address - Country:US
Mailing Address - Phone:480-922-4923
Mailing Address - Fax:480-922-4924
Practice Address - Street 1:15612 N 32ND ST
Practice Address - Street 2:STE. #3
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-3859
Practice Address - Country:US
Practice Address - Phone:602-251-8052
Practice Address - Fax:602-251-8068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-16
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207ZP0102X
AZ13453 STATE LICENSE207ZP0102X
AZ03D1074399 CLIA207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ432137Medicaid
AZZ70937Medicare PIN
AZ432137Medicaid