Provider Demographics
NPI:1902865611
Name:WEST SUBURBAN PATHOLOGY CONSULTANTS PA
Entity Type:Organization
Organization Name:WEST SUBURBAN PATHOLOGY CONSULTANTS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:DALY
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-993-5290
Mailing Address - Street 1:PO BOX 385760
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55438-5760
Mailing Address - Country:US
Mailing Address - Phone:952-944-0970
Mailing Address - Fax:
Practice Address - Street 1:6500 EXCELSIOR BLVD
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55426-4702
Practice Address - Country:US
Practice Address - Phone:952-993-5290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN18722WEOtherBLUE SHIELD
MN18722WEOtherBLUE SHIELD