Basic Information
| Provider Information | |||||||||
| NPI: | 1992818900 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILLIAMSPORT PATHOLOGY ASSOCS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5700 SOUTHWYCK BLVD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436141509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002888325 | ||||||||
| FaxNumber: | 4198664553 | ||||||||
| Practice Location | |||||||||
| Address1: | 777 RURAL AVE | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177013109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703212321 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | DILLMAN | ||||||||
| AuthorizedOfficialFirstName: | NICHOLAS | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 8002888325 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 08/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | PA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 0009692280005 | 05 | PA | MEDICAID | CC4291 | 01 | PA | RR MEDICARE | OTHER | 400563 | 01 | PA | HIGHMARK/BLUE SHIELD | OTHER | 0009692280003 | 05 | PA | MEDICAID |