Basic Information
| Provider Information | |||||||||
| NPI: | 1205825742 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AQUINAS PATHOLOGY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 460 TOTTEN POND RD | ||||||||
| Address2: | C/O MZI | ||||||||
| City: | WALTHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024511991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7818909933 | ||||||||
| FaxNumber: | 7818909950 | ||||||||
| Practice Location | |||||||||
| Address1: | 70 EAST ST | ||||||||
| Address2: | PATHOLOGY DEPT | ||||||||
| City: | METHUEN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018444597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786870156 | ||||||||
| FaxNumber: | 9786915709 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2005 | ||||||||
| LastUpdateDate: | 03/16/2010 | ||||||||
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| AuthorizedOfficialLastName: | ROSS | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9786870156 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 9779345 | 05 | MA | MEDICAID | M16489 | 01 | MA | BCBS | OTHER | 611620 | 01 | MA | TUFTS | OTHER |