Provider Demographics
NPI:1568492270
Name:CARLSON PATHOLOGY ASSOCIATES, PC
Entity Type:Organization
Organization Name:CARLSON PATHOLOGY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DESIREE
Authorized Official - Middle Name:A
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-941-7414
Mailing Address - Street 1:680 CENTRE ST
Mailing Address - Street 2:PATHOLOGY DEPARTMENT
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-3308
Mailing Address - Country:US
Mailing Address - Phone:508-941-7414
Mailing Address - Fax:508-941-6295
Practice Address - Street 1:680 CENTRE ST
Practice Address - Street 2:PATHOLOGY DEPARTMENT
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-3308
Practice Address - Country:US
Practice Address - Phone:508-941-7414
Practice Address - Fax:508-941-6295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9769978Medicaid
MA9769978Medicaid