Provider Demographics
NPI:1275740987
Name:OUTPATIENT CYTOPATHOLOGY CENTER
Entity Type:Organization
Organization Name:OUTPATIENT CYTOPATHOLOGY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-283-4734
Mailing Address - Street 1:PO BOX 2484
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37605-2484
Mailing Address - Country:US
Mailing Address - Phone:423-283-4734
Mailing Address - Fax:423-283-4736
Practice Address - Street 1:2400 SUSANNAH ST
Practice Address - Street 2:SUITE A
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601
Practice Address - Country:US
Practice Address - Phone:423-283-4734
Practice Address - Fax:423-283-4736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD020455207ZC0500X
207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Single Specialty
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3730678Medicare ID - Type Unspecified