Provider Demographics
NPI:1063619922
Name:MATTISON PATHOLOGY, L.L.P.
Entity type:Organization
Organization Name:MATTISON PATHOLOGY, L.L.P.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:M
Authorized Official - Last Name:WOLGAMOT
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:866-987-7284
Mailing Address - Street 1:3560 MERIDIAN ST STE 101
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1731
Mailing Address - Country:US
Mailing Address - Phone:360-734-2800
Mailing Address - Fax:360-734-3818
Practice Address - Street 1:4245 N CENTRAL EXPY STE 420
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75205-4566
Practice Address - Country:US
Practice Address - Phone:866-987-7284
Practice Address - Fax:469-232-9927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45D1065927OtherCLIA
TX7187034OtherCOLLEGE OF AMERICAN PATHOLOGISTS
TX45D1015603OtherCLIA
TX7201511OtherCOLLEGE OF AMERICAN PATHOLOGISTS
00Z224OtherMEDICARE PTAN
TX45D1069527OtherCLIA #