Provider Demographics
NPI:1275589624
Name:DERMATOPATH LAB, INC.
Entity Type:Organization
Organization Name:DERMATOPATH LAB, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:C
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-226-5540
Mailing Address - Street 1:555 PLEASANT ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02703-2400
Mailing Address - Country:US
Mailing Address - Phone:508-226-5540
Mailing Address - Fax:508-226-9619
Practice Address - Street 1:555 PLEASANT ST
Practice Address - Street 2:SUITE 106
Practice Address - City:ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703-2400
Practice Address - Country:US
Practice Address - Phone:508-226-5540
Practice Address - Fax:508-226-9619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2413207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1847-0OtherBCBS
MA350062OtherUHC
MAC028629OtherCHAMPUS
MA0805548Medicaid
RI9418065Medicaid
MA228418OtherBCBS
MA607206OtherTUFTS
MA0013986OtherNHP
RI1171OtherNHP
MA4754 MIROtherHARVARD/PILGRIM
RI9418065Medicaid