Provider Demographics
NPI:1629063938
Name:SKIN PATHOLOGY SERVICES INC
Entity Type:Organization
Organization Name:SKIN PATHOLOGY SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:T
Authorized Official - Last Name:BRODELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-393-4003
Mailing Address - Street 1:2660 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44483-6204
Mailing Address - Country:US
Mailing Address - Phone:330-393-4003
Mailing Address - Fax:330-393-0074
Practice Address - Street 1:2660 E MARKET ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44483-6204
Practice Address - Country:US
Practice Address - Phone:330-393-4003
Practice Address - Fax:330-393-0074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-13
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36D0656150291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0602922Medicaid
OH0602922Medicaid