Provider Demographics
NPI:1245302009
Name:MID-ATLANTIC PATHOLOGY SERVICES, INC.
Entity type:Organization
Organization Name:MID-ATLANTIC PATHOLOGY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:GRATTENDICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-626-5512
Mailing Address - Street 1:1355 RIVER BEND DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-4915
Mailing Address - Country:US
Mailing Address - Phone:214-638-2000
Mailing Address - Fax:844-751-9262
Practice Address - Street 1:405 GLENN DR
Practice Address - Street 2:SUITE 10-A
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20164-7119
Practice Address - Country:US
Practice Address - Phone:703-404-8189
Practice Address - Fax:703-404-1131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207ZP0102X
VA49D0898222291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAB020OtherCAREFIRST BLUE CROSS DC
MD4109007 00Medicaid
VA006601812Medicaid
VA200330OtherANTHEM BLUE CROSS
VA6902000000KU90OtherCAREFIRST NATIONAL ACCTS
VAKU90MIOtherCAREFIRST OF MARYLAND
VA137554OtherSOUTHERN HEALTHCARE
VA006601839Medicaid
VA690007157OtherRAILROAD MEDICARE
MD4109007 00Medicaid