Provider Demographics
NPI:1497197461
Name:PATHLAB INC
Entity Type:Organization
Organization Name:PATHLAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAX
Authorized Official - Middle Name:
Authorized Official - Last Name:MIROT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-459-1984
Mailing Address - Street 1:PO BOX 609
Mailing Address - Street 2:
Mailing Address - City:HEREFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85615-0609
Mailing Address - Country:US
Mailing Address - Phone:520-335-1800
Mailing Address - Fax:520-335-2743
Practice Address - Street 1:4266 INDUSTRY DRIVE
Practice Address - Street 2:SUITE 1
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2255
Practice Address - Country:US
Practice Address - Phone:520-335-1800
Practice Address - Fax:520-335-2743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-19
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ207ZP0102X
AZ03D0713539291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ906255Medicaid
AZZ164047Medicare PIN