Provider Demographics
NPI:1235186800
Name:PATHGROUP LABS, LLC
Entity Type:Organization
Organization Name:PATHGROUP LABS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN/CHIEF MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:W
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-221-4400
Mailing Address - Street 1:5301 VIRGINIA WAY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-7541
Mailing Address - Country:US
Mailing Address - Phone:615-221-4474
Mailing Address - Fax:615-234-3774
Practice Address - Street 1:1511 WESTOVER TER STE 201
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7131
Practice Address - Country:US
Practice Address - Phone:615-221-4400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4052291U00000X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7001263Medicaid
C93014OtherCUMBERLAND HEALTHCARE
6345016OtherCIGNA
IN200460360AMedicaid
TN3404179Medicaid
KY37000619Medicaid
KY50001168OtherPASSPORT
610609600OtherUS DEPT OF LABOR
P00000604OtherRAILROAD MEDICARE
GA968201772AMedicaid
KY220815100OtherPASSPORT ADVANTAGE
MS01455767Medicaid
TN4056486OtherBLUE SHIELD
7375469OtherAETNA
TNTN0100OtherJOHN DEERE HERITAGE
TN100042158OtherPHP TENNCARE
GA968201772AMedicaid