Provider Demographics
NPI:1629187778
Name:PHOENIX PATHOLOGY LLC
Entity Type:Organization
Organization Name:PHOENIX PATHOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:S
Authorized Official - Last Name:ROSSET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-223-5537
Mailing Address - Street 1:P O BOX 9397
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-9397
Mailing Address - Country:US
Mailing Address - Phone:937-643-4049
Mailing Address - Fax:937-223-9979
Practice Address - Street 1:ONE ELIZABETH PLACE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45408-0000
Practice Address - Country:US
Practice Address - Phone:937-223-5537
Practice Address - Fax:937-223-9979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0824059Medicaid
OHPH9363731Medicare PIN
OHE84824Medicare UPIN