Provider Demographics
NPI:1639397953
Name:LAB OF PATH, PA
Entity Type:Organization
Organization Name:LAB OF PATH, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:H
Authorized Official - Last Name:GOLLEHER
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:501-268-8175
Mailing Address - Street 1:1915 W BEEBE CAPPS EXPY
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143-5012
Mailing Address - Country:US
Mailing Address - Phone:501-268-8175
Mailing Address - Fax:501-268-8337
Practice Address - Street 1:1915 W BEEBE CAPPS EXPY
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-5012
Practice Address - Country:US
Practice Address - Phone:501-268-8175
Practice Address - Fax:501-268-8337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC0253207ZP0102X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR04D0891911OtherCLIA NUMBER
AR770093602OtherBREASTCARE OTHER
AR770046609OtherBREASTCARE
AR2022102OtherCAP NUMBER
AR106515709Medicaid
ARMC0253OtherAR LICENSE
AR18019Medicare UPIN
AR56822Medicare ID - Type UnspecifiedPATHOLOGY MEDICARE NUMBER