Provider Demographics
NPI:1205896594
Name:BOYCE - BYNUM PATHOLOGY LABORATORIES, INC
Entity type:Organization
Organization Name:BOYCE - BYNUM PATHOLOGY LABORATORIES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:COTTEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-886-4600
Mailing Address - Street 1:200 PORTLAND ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6525
Mailing Address - Country:US
Mailing Address - Phone:573-886-4600
Mailing Address - Fax:573-886-4695
Practice Address - Street 1:200 PORTLAND ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201
Practice Address - Country:US
Practice Address - Phone:573-886-4600
Practice Address - Fax:573-886-4695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO26D0652373291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
120064OtherBLUE CROSS BLUE SHIELD
AR126758709Medicaid
KS100455390BMedicaid
700595812OtherMISSOURI CARE
MO700595812Medicaid
OH275331Medicaid
KY6593789800Medicaid
IL36079966Medicaid
OK20030120AMedicaid
LA2194119Medicaid
IN300000488Medicaid
MS8156825Medicaid
888497OtherMERCY CAREPLUS