Provider Demographics
NPI:1649597931
Name:NORTHSIDE PATHOLOGY GROUP, PLLC
Entity Type:Organization
Organization Name:NORTHSIDE PATHOLOGY GROUP, PLLC
Other - Org Name:NPG
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT / MANAGER MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:CERVANTES-VAZQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:832-638-6072
Mailing Address - Street 1:510 W TIDWELL RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77091-4339
Mailing Address - Country:US
Mailing Address - Phone:281-618-8515
Mailing Address - Fax:281-618-8634
Practice Address - Street 1:510 W TIDWELL RD
Practice Address - Street 2:PATHOLOGY DEPT.
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77091-4339
Practice Address - Country:US
Practice Address - Phone:281-618-8504
Practice Address - Fax:713-401-0770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-26
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB104047OtherMEDICARE GROUP PTAN
TX217596001Medicaid
TX45D2028677OtherCLIA