1700860434 NPI number — AMERIPATH LUBBOCK 5.01(A) CORPORATION

Table of content: (NPI 1700860434)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700860434 NPI number — AMERIPATH LUBBOCK 5.01(A) CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMERIPATH LUBBOCK 5.01(A) CORPORATION
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:
Provider Other Organization Name Type Code:
6
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:
1700860434
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14275 MIDWAY RD
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
ADDISON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75001-3614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
610-271-4245

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 PENNSYLVANIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76104-2113
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-432-1100
Provider Business Practice Location Address Fax Number:
713-432-0221
Provider Enumeration Date:
12/06/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WHEELER
Authorized Official First Name:
DARREN
Authorized Official Middle Name:
THOMAS
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
702-733-7866

Provider Taxonomy Codes

  • Taxonomy code: 207ZP0102X , with the licence number:  45D0701182 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 121877803 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200393940A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0T841 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 45D0914073 . This is a "CLIA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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