Provider Demographics
NPI:1144595208
Name:DUCKWORTH PATHOLOGY GROUP REFERENCE LAB
Entity Type:Organization
Organization Name:DUCKWORTH PATHOLOGY GROUP REFERENCE LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:F
Authorized Official - Last Name:O'BRIEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-725-7551
Mailing Address - Street 1:1265 UNION AVE
Mailing Address - Street 2:5TH FLOOR SHERROD WING
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-3415
Mailing Address - Country:US
Mailing Address - Phone:901-725-7551
Mailing Address - Fax:901-725-9721
Practice Address - Street 1:1265 UNION AVE
Practice Address - Street 2:5TH FLOOR SHERROD WING
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-3415
Practice Address - Country:US
Practice Address - Phone:901-725-7551
Practice Address - Fax:901-725-9721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-21
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3282291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN44D0913215OtherCLIA