Provider Demographics
NPI:1265477707
Name:PATHOLOGISTS BIO-MEDICAL LABORATORIES PLLC
Entity Type:Organization
Organization Name:PATHOLOGISTS BIO-MEDICAL LABORATORIES PLLC
Other - Org Name:PATHOLOGISTS BIO-MEDICAL LABORATORIES LLP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:A
Authorized Official - Last Name:DYSERT
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:214-818-9100
Mailing Address - Street 1:3600 GASTON AVE
Mailing Address - Street 2:WADLEY TOWER, SUITE 261
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1800
Mailing Address - Country:US
Mailing Address - Phone:214-818-9100
Mailing Address - Fax:214-818-9170
Practice Address - Street 1:3500 GASTON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-2096
Practice Address - Country:US
Practice Address - Phone:214-818-9100
Practice Address - Fax:214-818-9170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127290802Medicaid
TXCR0446OtherRAILROAD MEDICARE
TX127290802Medicaid