Basic Information
| Provider Information | |||||||||
| NPI: | 1225033939 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDWESTERN PATHOLOGY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6810 RELIABLE PARKWAY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606860001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002888325 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1521 GULL RD | ||||||||
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| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490481640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2692667231 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | SCOTT | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2692267231 | ||||||||
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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 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 220C960410 | 01 | MI | BLUE CROSS | OTHER |