Basic Information
| Provider Information | |||||||||
| NPI: | 1548224009 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PINEHURST PATHOLOGY CENTER INC | ||||||||
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| OtherOrganizationName: | PINEHURST PATHOLOGY CENTER INC INDEPENDENT LAB | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5700 SOUTHWYCK BLVD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436141509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002888325 | ||||||||
| FaxNumber: | 4198665453 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107151156 | ||||||||
| FaxNumber: | 9107151944 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 04/28/2022 | ||||||||
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| AuthorizedOfficialLastName: | DIFURIO | ||||||||
| AuthorizedOfficialFirstName: | MEGAN | ||||||||
| AuthorizedOfficialMiddleName: | JUSTINE | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9107151156 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PINEHURST PATHOLOGY CENTER INC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZD0900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology | 291U00000X | N | Laboratories | Clinical Medical Laboratory | 207ZP0102X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 8902399 | 05 | NC | MEDICAID | 02399 | 01 | NC | BCBS | OTHER |