Provider Demographics
NPI:1275778219
Name:PATHOLOGY LABS OF AR
Entity Type:Organization
Organization Name:PATHOLOGY LABS OF AR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:E
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-225-7711
Mailing Address - Street 1:1 LILE CT
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6242
Mailing Address - Country:US
Mailing Address - Phone:501-225-7711
Mailing Address - Fax:501-225-7108
Practice Address - Street 1:1 LILE CT
Practice Address - Street 2:SUITE 101
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6242
Practice Address - Country:US
Practice Address - Phone:501-225-7711
Practice Address - Fax:501-225-7108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-04
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR18132OtherMEDICARE PTAN
AR104544002Medicaid