Provider Demographics
NPI:1184636821
Name:PATHOLOGY ASSOCIATES OF GRAND RAPIDS, P.C.
Entity Type:Organization
Organization Name:PATHOLOGY ASSOCIATES OF GRAND RAPIDS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SARAT
Authorized Official - Middle Name:C
Authorized Official - Last Name:KHANDAVALLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-252-7249
Mailing Address - Street 1:PO BOX 1629
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45802-1629
Mailing Address - Country:US
Mailing Address - Phone:877-378-4293
Mailing Address - Fax:419-223-2726
Practice Address - Street 1:200 JEFFERSON AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-364-6700
Practice Address - Fax:616-364-4960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1295996916Medicaid