Provider Demographics
NPI:1811988025
Name:WEST CENTRAL PATHOLOGY AND LABORATORY MEDICINE PA
Entity type:Organization
Organization Name:WEST CENTRAL PATHOLOGY AND LABORATORY MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PATHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:REID
Authorized Official - Last Name:SPANBAUER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:320-762-6068
Mailing Address - Street 1:2800 CAMPUS DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-2606
Mailing Address - Country:US
Mailing Address - Phone:763-201-0492
Mailing Address - Fax:
Practice Address - Street 1:111 17TH AVE E
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-3703
Practice Address - Country:US
Practice Address - Phone:320-762-6068
Practice Address - Fax:320-762-6145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1619967890OtherNPI ENUMERATOR
MND197OtherUCARE
MN113212100Medicaid
MNDA8276OtherRR MEDICARE
MN1134119324OtherNPI ENUMERATOR
MNC03345Medicare PIN