Provider Demographics
NPI:1407040827
Name:RALEIGH PATHOLOGY RESOURCES INC
Entity Type:Organization
Organization Name:RALEIGH PATHOLOGY RESOURCES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SUKJUNG
Authorized Official - Middle Name:GERALD
Authorized Official - Last Name:KOH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-256-4157
Mailing Address - Street 1:39 FOX SPARROW RD
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3687
Mailing Address - Country:US
Mailing Address - Phone:304-256-4157
Mailing Address - Fax:
Practice Address - Street 1:1710 HARPER RD
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3357
Practice Address - Country:US
Practice Address - Phone:304-256-4157
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0204127000Medicaid
WV0204127000Medicaid