Provider Demographics
NPI:1811982549
Name:PATHOLOGY SERVICES PC
Entity type:Organization
Organization Name:PATHOLOGY SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BROUILLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:308-532-4700
Mailing Address - Street 1:1931 WEST A ST
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101
Mailing Address - Country:US
Mailing Address - Phone:308-532-4700
Mailing Address - Fax:308-534-0534
Practice Address - Street 1:1931 WEST A ST
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101
Practice Address - Country:US
Practice Address - Phone:308-532-4700
Practice Address - Fax:308-534-0534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-19
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE15625207ND0900X, 207NS0135X
NE28D0456332291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE092280Medicare ID - Type Unspecified
NE01957OtherBLUE CROSS BLUE SHIELD
NE094313Medicare ID - Type Unspecified
CO98000912Medicaid
NE=========13Medicaid
SD5580030Medicaid
NE=========00Medicaid