Provider Demographics
NPI: | 1760618904 |
---|---|
Name: | AFFILIATED PATHOLOGY LAB |
Entity Type: | Organization |
Organization Name: | AFFILIATED PATHOLOGY LAB |
Other - Org Name: | AFFILIATED PATHOLOGY LAB |
Other - Org Type: | Other Name |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JEFFREY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | ROSS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 518-262-3738 |
Mailing Address - Street 1: | PO BOX 909 |
Mailing Address - Street 2: | |
Mailing Address - City: | LATHAM |
Mailing Address - State: | NY |
Mailing Address - Zip Code: | 12110-0909 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 518-786-1298 |
Mailing Address - Fax: | 518-786-1293 |
Practice Address - Street 1: | 47 NEW SCOTLAND AVE |
Practice Address - Street 2: | |
Practice Address - City: | ALBANY |
Practice Address - State: | NY |
Practice Address - Zip Code: | 12208-3412 |
Practice Address - Country: | US |
Practice Address - Phone: | 518-262-3738 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | AFFILIATED PATHOLOGY LAB |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2009-06-02 |
Last Update Date: | 2009-06-02 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207ZP0101X | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | Group - Single Specialty |