Provider Demographics
NPI:1992119127
Name:ALLIED PATHOLOGY, PC
Entity type:Organization
Organization Name:ALLIED PATHOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALDINE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-255-1000
Mailing Address - Street 1:PO BOX 727
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0727
Mailing Address - Country:US
Mailing Address - Phone:509-255-1000
Mailing Address - Fax:
Practice Address - Street 1:112 S GREENRIDGE DR
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-9566
Practice Address - Country:US
Practice Address - Phone:509-255-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-16
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA603411100291U00000X, 207ZD0900X, 207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic PathologyGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G8930333OtherMEDICARE ID
ID1992119127Medicaid