Provider Demographics
NPI:1609826304
Name:INTERPACE DIAGNOSTICS CORPORATION
Entity Type:Organization
Organization Name:INTERPACE DIAGNOSTICS CORPORATION
Other - Org Name:REDPATH INTEGRATED PATHOLOGY, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:W
Authorized Official - Last Name:BURNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-613-4184
Mailing Address - Street 1:2515 LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15222-4613
Mailing Address - Country:US
Mailing Address - Phone:412-224-6100
Mailing Address - Fax:412-224-6110
Practice Address - Street 1:2515 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15222-4613
Practice Address - Country:US
Practice Address - Phone:412-224-6100
Practice Address - Fax:412-224-6110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA39D1024654291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101-855-645-000-1Medicaid
PA001686800OtherHIGHMARK BS
PA101-855-645-000-1Medicaid