Provider Demographics
NPI:1295717056
Name:JPB PATHOLOGY, INC
Entity type:Organization
Organization Name:JPB PATHOLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLENWIDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-397-0913
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-0428
Mailing Address - Country:US
Mailing Address - Phone:662-232-8121
Mailing Address - Fax:662-236-5236
Practice Address - Street 1:1100 BELK BLVD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5242
Practice Address - Country:US
Practice Address - Phone:800-362-0858
Practice Address - Fax:662-534-7188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-17
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS25D0859785207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02271856Medicaid
MS429087482OtherBLUE CROSS
DO6485OtherRAILROAD MEDICARE
DO6485OtherRAILROAD MEDICARE
MS512G700045Medicare PIN