1669433272 NPI number — DESERT PATHOLOGY SERVICES PA

Table of content: (NPI 1669433272)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669433272 NPI number — DESERT PATHOLOGY SERVICES PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DESERT PATHOLOGY SERVICES PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GLEN C FRIEDMAN MD PA
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669433272
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 740968
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75374-0968
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
915-521-1341
Provider Business Mailing Address Fax Number:
915-521-1494

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1801 NORTH OREGON STREET
Provider Second Line Business Practice Location Address:
DEPARTMENT OF PATHOLOGY
Provider Business Practice Location Address City Name:
EL PASO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79902-3591
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-521-1341
Provider Business Practice Location Address Fax Number:
915-521-1494
Provider Enumeration Date:
03/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FRIEDMAN
Authorized Official First Name:
GLEN
Authorized Official Middle Name:
CURTIS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
915-521-1341

Provider Taxonomy Codes

  • Taxonomy code: 207ZC0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 31455859 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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