Provider Demographics
NPI:1366683971
Name:AUDUBON PATHOLOGY LLC
Entity Type:Organization
Organization Name:AUDUBON PATHOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:P
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-361-3757
Mailing Address - Street 1:1141 WHITNEY AVE BLDG 3
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70056-5011
Mailing Address - Country:US
Mailing Address - Phone:504-361-3757
Mailing Address - Fax:504-361-3132
Practice Address - Street 1:1141 WHITNEY AVE BLDG 3
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-5011
Practice Address - Country:US
Practice Address - Phone:504-361-3757
Practice Address - Fax:504-361-3132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-11
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023755207ZD0900X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAH82850Medicare UPIN