Provider Demographics
NPI:1588674980
Name:WESTERN PATHOLOGY CONSULTANTS, PC
Entity Type:Organization
Organization Name:WESTERN PATHOLOGY CONSULTANTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:308-630-1919
Mailing Address - Street 1:PO BOX 1886
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-1886
Mailing Address - Country:US
Mailing Address - Phone:308-632-2900
Mailing Address - Fax:308-632-2902
Practice Address - Street 1:4021 AVENUE B
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4602
Practice Address - Country:US
Practice Address - Phone:308-630-1919
Practice Address - Fax:308-632-7053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NECF9907OtherRAILROAD MEDICARE
SD558-0550Medicaid
NE=========01Medicaid
NE=========01Medicaid