Provider Demographics
NPI:1336255538
Name:PATHOLOGY SERVICES.ORG LLC
Entity Type:Organization
Organization Name:PATHOLOGY SERVICES.ORG LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LIMITED MEMBER/SOLE OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:WORLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CT,ASCP,IAC
Authorized Official - Phone:231-590-5030
Mailing Address - Street 1:PO BOX 70
Mailing Address - Street 2:ATT'N LISA WORLEY
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-0070
Mailing Address - Country:US
Mailing Address - Phone:231-590-5030
Mailing Address - Fax:
Practice Address - Street 1:1465 E PARKDALE AVE
Practice Address - Street 2:CYTOPATHOLOGY/INDEPENDENT LABORATORY
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-0070
Practice Address - Country:US
Practice Address - Phone:231-590-5030
Practice Address - Fax:231-889-5969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246R00000X
MI23D0981736291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No246R00000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4280673Medicaid
MI0E11500OtherBLUE CROSS BLUE SHIELDPPO
MI71020000E11500OtherBCBS OF MICHIGAN
MI0E11500OtherBLUE CROSS BLUE SHIELDPPO
MI=========OtherPRIORITY HEALTH
MI=========OtherASR
MI71020000E11500OtherBCBS OF MICHIGAN
MI=========OtherGOLDENRULE
MI=========OtherCOMMUNITY CHOICE MICHIGAN
MI=========OtherIRA HEALTH PLAN
MI=========OtherTENCON HEALTH PLAN CORP