Provider Demographics
NPI:1710008719
Name:CYTODX PHYSICIAN SERVICES
Entity Type:Organization
Organization Name:CYTODX PHYSICIAN SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MCNICHOLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:978-548-5204
Mailing Address - Street 1:200 CORPORATE PL
Mailing Address - Street 2:SUITE #8
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-3840
Mailing Address - Country:US
Mailing Address - Phone:978-548-5204
Mailing Address - Fax:978-535-1934
Practice Address - Street 1:200 CORPORATE PL
Practice Address - Street 2:SUITE #8
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-3840
Practice Address - Country:US
Practice Address - Phone:978-548-5204
Practice Address - Fax:978-535-1934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207ZC0500X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Single Specialty
Not Answered207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MACYM16695OtherBLUE CROSS PROVIDER #
MA9781129Medicaid
MAM20409Medicare ID - Type UnspecifiedPROVIDER NUMBER