Provider Demographics
NPI:1871679704
Name:PETERSBURG PATHOLOGY ASSOCIATES LTD.
Entity Type:Organization
Organization Name:PETERSBURG PATHOLOGY ASSOCIATES LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:T
Authorized Official - Last Name:SIEGMUND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-862-5010
Mailing Address - Street 1:PO BOX 8909
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32239-0909
Mailing Address - Country:US
Mailing Address - Phone:804-765-5026
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9274
Practice Address - Country:US
Practice Address - Phone:804-765-5026
Practice Address - Fax:804-862-5582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA055573OtherBCBS
VAC00136Medicare PIN
VA055573OtherBCBS