Provider Demographics
NPI:1619969870
Name:MAPLEWOOD PATHOLOGY PC
Entity Type:Organization
Organization Name:MAPLEWOOD PATHOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LISLE
Authorized Official - Middle Name:
Authorized Official - Last Name:EATON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-525-1424
Mailing Address - Street 1:PO BOX 8870
Mailing Address - Street 2:MAPLEWOOD PATHOLOGY
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-0870
Mailing Address - Country:US
Mailing Address - Phone:518-525-1424
Mailing Address - Fax:
Practice Address - Street 1:315 S MANNING BLVD
Practice Address - Street 2:SPH PATHOLOGY
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-1707
Practice Address - Country:US
Practice Address - Phone:518-525-1474
Practice Address - Fax:518-525-6750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-15
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY33DPFI0004OtherCLIA
NY33D0162320OtherCLIA
NY33DPFI0004OtherCLIA