Provider Demographics
NPI:1457407124
Name:GATEWAY PATHOLOGY ASSOC
Entity Type:Organization
Organization Name:GATEWAY PATHOLOGY ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ELPIDIO
Authorized Official - Middle Name:G
Authorized Official - Last Name:MARIANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:563-242-5316
Mailing Address - Street 1:PO BOX 0361
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52733-0361
Mailing Address - Country:US
Mailing Address - Phone:563-242-5316
Mailing Address - Fax:563-242-3128
Practice Address - Street 1:1410 N 4TH STREET
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732
Practice Address - Country:US
Practice Address - Phone:563-242-5316
Practice Address - Fax:563-242-3128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21940207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA31964OtherBC BS
IA0477950Medicaid
DC6462OtherRR MEDICARE
DC6462OtherRR MEDICARE
A03872Medicare UPIN