Provider Demographics
NPI:1467597062
Name:INDIANA PATHOLOGY CONSULTANTS, INC.
Entity Type:Organization
Organization Name:INDIANA PATHOLOGY CONSULTANTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MAX
Authorized Official - Middle Name:L
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-432-5867
Mailing Address - Street 1:3240B MALLARD COVE LN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-2883
Mailing Address - Country:US
Mailing Address - Phone:260-432-5867
Mailing Address - Fax:260-436-9013
Practice Address - Street 1:7950 WEST JEFFERSON BLVD.
Practice Address - Street 2:PATHOLOGY DEPARTMENT
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804
Practice Address - Country:US
Practice Address - Phone:260-435-7154
Practice Address - Fax:260-435-7633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN50000730A207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100053700BMedicaid
CN1365OtherRAILROAD
IN100053700BMedicaid