Provider Demographics
NPI:1922079706
Name:CLIN-PATH PATHOLOGY
Entity Type:Organization
Organization Name:CLIN-PATH PATHOLOGY
Other - Org Name:CLIN-PATH PATHOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANTOINETTE
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:DEZORZI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-685-5166
Mailing Address - Street 1:PO BOX 42210
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85080-2210
Mailing Address - Country:US
Mailing Address - Phone:623-889-7403
Mailing Address - Fax:623-889-7407
Practice Address - Street 1:424 S 56TH ST STE 110
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85034-2177
Practice Address - Country:US
Practice Address - Phone:602-685-5211
Practice Address - Fax:602-685-5325
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLIN-PATH ASSOCIATES, PLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-30
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ647787Medicaid
AZ647787Medicaid