Provider Demographics
NPI:1356445969
Name:SOUTHWEST PATHOLOGY, INC
Entity Type:Organization
Organization Name:SOUTHWEST PATHOLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:DR
Authorized Official - First Name:MELVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:VAN BOVEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-582-0001
Mailing Address - Street 1:PO BOX 26303
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-0303
Mailing Address - Country:US
Mailing Address - Phone:918-582-0001
Mailing Address - Fax:918-582-0003
Practice Address - Street 1:8803 S. 101ST E. AVE
Practice Address - Street 2:SUITE 360
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133
Practice Address - Country:US
Practice Address - Phone:918-582-0001
Practice Address - Fax:918-582-0003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100739510AMedicaid
KS100245110AMedicaid
MO703687004Medicaid
TN4033986OtherBLUECROSS BLUESHIELD
TN4033986OtherBLUE CROSS BLUE SHIELD
175079901OtherDEPT OF LABOR