Provider Demographics
NPI:1396717054
Name:AMERIPATH CONSULTING PATHOLOGY SERVICES PA
Entity type:Organization
Organization Name:AMERIPATH CONSULTING PATHOLOGY SERVICES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:H
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-932-8270
Mailing Address - Street 1:2560 N. SHADELAND AVENUE
Mailing Address - Street 2:SUITE A
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-1706
Mailing Address - Country:US
Mailing Address - Phone:317-275-8072
Mailing Address - Fax:317-275-8124
Practice Address - Street 1:568 RUIN CREEK RD
Practice Address - Street 2:SUITE 5
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-5921
Practice Address - Country:US
Practice Address - Phone:252-492-4477
Practice Address - Fax:252-436-1899
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMERIPATH INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-06
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34D0239955291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC02332OtherBCBS
NC015MVOtherBCBS NC
VA003480461Medicaid
SC1396717054Medicaid
NC7001174Medicaid
SC1396717054Medicaid
NC7001174Medicaid