Basic Information
| Provider Information | |||||||||
| NPI: | 1194944108 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MILTON PATHOLOGY ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 92 HIGHLAND ST | ||||||||
| Address2: | |||||||||
| City: | MILTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021863800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176964600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 92 HIGHLAND ST | ||||||||
| Address2: | |||||||||
| City: | MILTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021863800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176964600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KELLER | ||||||||
| AuthorizedOfficialFirstName: | JON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OF PATHOLOGY | ||||||||
| AuthorizedOfficialTelephone: | 6176964600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 9743383 | 05 | MA | MEDICAID | M15030 | 01 | MA | BLUE SHIELD PROVIDER # | OTHER |