Provider Demographics
NPI:1801033683
Name:AMERIPATH LUBBOCK 501A CORPORATION
Entity Type:Organization
Organization Name:AMERIPATH LUBBOCK 501A CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:KRAMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-550-3000
Mailing Address - Street 1:14275 MIDWAY RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3614
Mailing Address - Country:US
Mailing Address - Phone:214-932-8029
Mailing Address - Fax:610-271-4245
Practice Address - Street 1:117 E 19TH ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5151
Practice Address - Country:US
Practice Address - Phone:575-627-7000
Practice Address - Fax:575-627-7007
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMERIPATH INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-15
Last Update Date:2015-04-24
Deactivation Date:2011-02-01
Deactivation Code:
Reactivation Date:2011-09-20
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM07231083Medicaid