Basic Information
| Provider Information | |||||||||
| NPI: | 1316920309 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE PATHOLOGY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 477 | ||||||||
| Address2: | |||||||||
| City: | BELLEFONTAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433110477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002888325 | ||||||||
| FaxNumber: | 4198665453 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 PALMER AVENUE | ||||||||
| Address2: | |||||||||
| City: | BELLEFONTAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375924015 | ||||||||
| FaxNumber: | 4198665453 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 12/09/2013 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9375997015 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD, PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 35043604 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | CL0527 | 01 | RAILROAD MEDICARE | OTHER |