Provider Demographics
NPI:1912914144
Name:DERMATOPATHOLOGY LABORATORY OF CENTRAL STATES
Entity Type:Organization
Organization Name:DERMATOPATHOLOGY LABORATORY OF CENTRAL STATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:G
Authorized Official - Last Name:OLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:937-434-2351
Mailing Address - Street 1:7835 PARAGON RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4021
Mailing Address - Country:US
Mailing Address - Phone:937-434-2351
Mailing Address - Fax:937-434-1381
Practice Address - Street 1:7835 PARAGON RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459
Practice Address - Country:US
Practice Address - Phone:937-434-2351
Practice Address - Fax:937-434-1381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0222614Medicaid
OH0576541Medicaid