Provider Demographics
NPI:1265495923
Name:PATHOLOGY AT JEANES
Entity Type:Organization
Organization Name:PATHOLOGY AT JEANES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:CZULEWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-728-2040
Mailing Address - Street 1:7600 CENTRAL AVENUE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111
Mailing Address - Country:US
Mailing Address - Phone:215-728-2040
Mailing Address - Fax:215-728-2064
Practice Address - Street 1:7600 CENTRAL AVENUE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111
Practice Address - Country:US
Practice Address - Phone:215-728-2040
Practice Address - Fax:215-728-2064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-11
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1010060310001Medicaid
PA1010060310001Medicaid