Provider Demographics
NPI:1336160217
Name:LAKEWOOD PATHOLOGY ASSOCIATES, INC.
Entity Type:Organization
Organization Name:LAKEWOOD PATHOLOGY ASSOCIATES, INC.
Other - Org Name:INFORM DIAGNOSTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP MANAGED CARE
Authorized Official - Prefix:
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:PIRTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-309-2674
Mailing Address - Street 1:6655 NORTH MACARTHUR BOULEVARD
Mailing Address - Street 2:ATTN: MANAGED CARE DEPARTMENT
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-2443
Mailing Address - Country:US
Mailing Address - Phone:214-596-7031
Mailing Address - Fax:
Practice Address - Street 1:825 RAHWAY AVE
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-6633
Practice Address - Country:US
Practice Address - Phone:732-901-7575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0002824207ZP0102X, 291U00000X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ241845Medicare PIN
31D0909259OtherCLIA
NJ623547Medicare ID - Type Unspecified