Provider Demographics
NPI:1609868199
Name:MERCED PATHOLOGY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:MERCED PATHOLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:P
Authorized Official - Last Name:CARMICHAEL
Authorized Official - Suffix:IV
Authorized Official - Credentials:MD
Authorized Official - Phone:209-723-4551
Mailing Address - Street 1:3329 G ST
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-0964
Mailing Address - Country:US
Mailing Address - Phone:209-723-4551
Mailing Address - Fax:209-723-0141
Practice Address - Street 1:3329 G ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-0964
Practice Address - Country:US
Practice Address - Phone:209-723-4551
Practice Address - Fax:209-723-0141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-19
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLF1095291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALAB44024FMedicaid
CALAB44024FMedicaid
CALAB44024FMedicaid