Provider Demographics
NPI:1104472117
Name:PATHOLOGY GROUP OF LOUISIANA, A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:PATHOLOGY GROUP OF LOUISIANA, A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:HOOD
Authorized Official - Last Name:LANDRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-766-4999
Mailing Address - Street 1:5339 ODONOVAN DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4388
Mailing Address - Country:US
Mailing Address - Phone:225-766-4999
Mailing Address - Fax:225-767-4704
Practice Address - Street 1:5339 ODONOVAN DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4388
Practice Address - Country:US
Practice Address - Phone:225-766-4999
Practice Address - Fax:225-767-4704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0008291200OtherAETNA (GROUP)
LA1184781Medicaid
231798OtherWELLCARE
CS9840OtherRAILROAD MEDICARE
1794007OtherMEDICAID OTHER