Provider Demographics
NPI:1740240597
Name:BAYSIDE PATHOLOGY INC
Entity Type:Organization
Organization Name:BAYSIDE PATHOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:GOLDFOGEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-734-9033
Mailing Address - Street 1:1500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-4551
Mailing Address - Country:US
Mailing Address - Phone:360-734-9033
Mailing Address - Fax:360-734-0467
Practice Address - Street 1:1500 N STATE ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-4551
Practice Address - Country:US
Practice Address - Phone:360-734-9033
Practice Address - Fax:360-734-0467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD 23314291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7063092Medicaid
WA8916146OtherLABOR AND INDUSTRIES