Provider Demographics
NPI:1467436196
Name:NORTHEAST PATHOLOGY GROUP, PA
Entity Type:Organization
Organization Name:NORTHEAST PATHOLOGY GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLINE
Authorized Official - Middle Name:L
Authorized Official - Last Name:VALDES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-575-1111
Mailing Address - Street 1:PO BOX 207048
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-7048
Mailing Address - Country:US
Mailing Address - Phone:713-559-6929
Mailing Address - Fax:713-559-6928
Practice Address - Street 1:2701 HOSPITAL DRVIE
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-5748
Practice Address - Country:US
Practice Address - Phone:361-575-1111
Practice Address - Fax:361-573-5012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-06
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX374209001Medicaid
TXCQ4039OtherRAILROAD MEDICARE
TXCQ4039OtherRAILROAD MEDICARE