Provider Demographics
NPI:1275690588
Name:PUEBLO PATHOLOGY GROUP, PC
Entity Type:Organization
Organization Name:PUEBLO PATHOLOGY GROUP, PC
Other - Org Name:LABORATORY AND PATHOLOGY CONSULTANTS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCARTHY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:719-584-4427
Mailing Address - Street 1:200 S SANTA FE AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-4270
Mailing Address - Country:US
Mailing Address - Phone:719-542-0560
Mailing Address - Fax:719-542-0561
Practice Address - Street 1:400 W 16TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2745
Practice Address - Country:US
Practice Address - Phone:719-542-0560
Practice Address - Fax:719-542-0561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04310082Medicaid
CO04310082Medicaid