Provider Demographics
NPI:1235121831
Name:CORTLAND PATHOLOGY PC
Entity Type:Organization
Organization Name:CORTLAND PATHOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD-AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:JUN
Authorized Official - Middle Name:
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:607-756-3500
Mailing Address - Street 1:4567 CROSSROADS PARK DR
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-3589
Mailing Address - Country:US
Mailing Address - Phone:315-295-2100
Mailing Address - Fax:315-295-2125
Practice Address - Street 1:134 HOMER AVE
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-1206
Practice Address - Country:US
Practice Address - Phone:607-756-3500
Practice Address - Fax:607-756-3636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-19
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY201857207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY56889AMedicare PIN