Provider Demographics
NPI:1356530968
Name:BAYLESS PATHMARK INC
Entity type:Organization
Organization Name:BAYLESS PATHMARK INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:YILAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-826-0384
Mailing Address - Street 1:19250 BAGLEY RD STE 101
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-3348
Mailing Address - Country:US
Mailing Address - Phone:440-826-0384
Mailing Address - Fax:
Practice Address - Street 1:200 E STATE ST
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-4936
Practice Address - Country:US
Practice Address - Phone:330-596-7022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAYLESS PATHMARK INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-19
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2020682Medicaid
OH=========010OtherTRI CARE
OH=========09OtherBWC
OH2020682Medicaid