Provider Demographics
NPI:1447402391
Name:PATHOLOGY ASSOCIATES OF CENTRAL ILLI
Entity Type:Organization
Organization Name:PATHOLOGY ASSOCIATES OF CENTRAL ILLI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SANJAI
Authorized Official - Middle Name:
Authorized Official - Last Name:NAGENDRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:586-412-4379
Mailing Address - Street 1:44000 GARFIELD ROAD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038
Mailing Address - Country:US
Mailing Address - Phone:586-412-4379
Mailing Address - Fax:586-412-4102
Practice Address - Street 1:200 HEALTHCARE DRIVE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246-1154
Practice Address - Country:US
Practice Address - Phone:618-664-1230
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-22
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCC5544OtherRRMC
IL205578Medicare PIN