Provider Demographics
NPI:1912915828
Name:DERMATOPATHOLOGY LABORATORY OF NEW ENGLAND PC
Entity Type:Organization
Organization Name:DERMATOPATHOLOGY LABORATORY OF NEW ENGLAND PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:SHAPIRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-630-2666
Mailing Address - Street 1:140 GREEN RD
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-6612
Mailing Address - Country:US
Mailing Address - Phone:203-630-2666
Mailing Address - Fax:203-630-2909
Practice Address - Street 1:140 GREEN RD
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-6612
Practice Address - Country:US
Practice Address - Phone:203-630-2666
Practice Address - Fax:203-630-2909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT029159207N00000X
CTCL0562291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
070CL0562CT01OtherANTHEM BCBS
CT004236081Medicaid
070CL0562CT01OtherANTHEM BCBS