Provider Demographics
NPI:1063554129
Name:NORTHERN STAR PATHOLOGY, P.C.
Entity type:Organization
Organization Name:NORTHERN STAR PATHOLOGY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOTTLIEB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:906-226-9127
Mailing Address - Street 1:2837 US HIGHWAY 41 W
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2252
Mailing Address - Country:US
Mailing Address - Phone:906-225-3964
Mailing Address - Fax:906-226-3875
Practice Address - Street 1:3401 LUDINGTON ST
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-1300
Practice Address - Country:US
Practice Address - Phone:906-226-9127
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301406387207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI220520070OtherBLUE CROSS BLUE SHIELD MI
MI104194270Medicaid
MI0N10860001Medicare PIN
MI220520070OtherBLUE CROSS BLUE SHIELD MI
220028718Medicare PIN
DG6507Medicare PIN
MI0N10860Medicare PIN