Provider Demographics
NPI:1336107143
Name:NORTHEAST PATHOLOGY ASSOCIATES, PC
Entity Type:Organization
Organization Name:NORTHEAST PATHOLOGY ASSOCIATES, PC
Other - Org Name:NORTHEAST IOWA PATHOLOGY ASSOCIATES, PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:A
Authorized Official - Last Name:NICKELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-235-3679
Mailing Address - Street 1:PO BOX 2818
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50704-2818
Mailing Address - Country:US
Mailing Address - Phone:319-233-3044
Mailing Address - Fax:319-233-0722
Practice Address - Street 1:1825 LOGAN AVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-1916
Practice Address - Country:US
Practice Address - Phone:319-235-3679
Practice Address - Fax:319-233-0722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA08952Medicare PIN