Provider Demographics
NPI:1285667717
Name:IRVING LABORATORIES PA
Entity Type:Organization
Organization Name:IRVING LABORATORIES PA
Other - Org Name:IRVING LABORATORIES INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:BELTON
Authorized Official - Last Name:KETCHERSID
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-579-8291
Mailing Address - Street 1:PO BOX 201624
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-1624
Mailing Address - Country:US
Mailing Address - Phone:972-271-9805
Mailing Address - Fax:972-840-2884
Practice Address - Street 1:1901 N MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061
Practice Address - Country:US
Practice Address - Phone:972-271-9805
Practice Address - Fax:972-840-2884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXBB07OtherBLUE CROSS
TXBB07Medicare ID - Type Unspecified