Provider Demographics
NPI:1619974573
Name:KNOXVILLE DERMATOPATHOLOGY LABORATORY LLC
Entity Type:Organization
Organization Name:KNOXVILLE DERMATOPATHOLOGY LABORATORY LLC
Other - Org Name:PAUL B GOOGE M.D.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-584-1933
Mailing Address - Street 1:11124 KINGSTON PIKE STE 119-407
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-2863
Mailing Address - Country:US
Mailing Address - Phone:865-584-1933
Mailing Address - Fax:865-584-1323
Practice Address - Street 1:114 LOVELL RD STE 202
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-1984
Practice Address - Country:US
Practice Address - Phone:865-584-1933
Practice Address - Fax:865-584-1323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-06
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3716698Medicaid
TN3716698Medicaid
TNCI8843Medicare PIN