Provider Demographics
NPI:1700860962
Name:PEDIATRIC PATHOLOGY ASSOCIATES OF COLUMBUS INC
Entity Type:Organization
Organization Name:PEDIATRIC PATHOLOGY ASSOCIATES OF COLUMBUS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHAMLAL
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-722-5315
Mailing Address - Street 1:DEPT 781676
Mailing Address - Street 2:PO BOX 78000
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1676
Mailing Address - Country:US
Mailing Address - Phone:614-722-5315
Mailing Address - Fax:614-722-3033
Practice Address - Street 1:700 CHILDRENS DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2664
Practice Address - Country:US
Practice Address - Phone:614-722-5315
Practice Address - Fax:614-722-3033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-01
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36D0665271207ZP0102X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2066688Medicaid
OH000000122252OtherBCBS
5907692OtherAETNA
5907692OtherAETNA