Provider Demographics
NPI:1265407738
Name:ST JOSEPHS PATHOLOGY
Entity type:Organization
Organization Name:ST JOSEPHS PATHOLOGY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:623-889-7403
Mailing Address - Street 1:PO BOX 678027
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8027
Mailing Address - Country:US
Mailing Address - Phone:602-943-9200
Mailing Address - Fax:316-652-0340
Practice Address - Street 1:350 W THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4409
Practice Address - Country:US
Practice Address - Phone:602-406-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-20
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAX4478OtherHEALTH NET OF AZ
AZAZ0182900OtherBCBSAZ
AZ454760Medicaid
AZCE9122Medicare PIN
AZAX4478OtherHEALTH NET OF AZ