Provider Demographics
NPI:1780864280
Name:WILMINGTON PATHOLOGY LABORATORY INC
Entity Type:Organization
Organization Name:WILMINGTON PATHOLOGY LABORATORY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:SHIRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-362-9511
Mailing Address - Street 1:PO BOX 20169
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-0506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1915 S 17TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6683
Practice Address - Country:US
Practice Address - Phone:910-362-9511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2008-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC018F3OtherBCBS OF NORTH CAROLINA
NC7001334Medicaid
P00627249OtherRAILROAD MEDICARE
P00627249OtherRAILROAD MEDICARE