Provider Demographics
NPI:1104855717
Name:PATHOLOGISTS BIO-MEDICAL LABORATORIES PLLC
Entity type:Organization
Organization Name:PATHOLOGISTS BIO-MEDICAL LABORATORIES PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:A
Authorized Official - Last Name:DYSERT
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:214-823-6492
Mailing Address - Street 1:3600 GASTON AVE
Mailing Address - Street 2:WADLEY TOWER, SUITE 261
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1800
Mailing Address - Country:US
Mailing Address - Phone:214-818-9100
Mailing Address - Fax:214-818-9170
Practice Address - Street 1:1111 NORTHPOINT DR
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-3831
Practice Address - Country:US
Practice Address - Phone:972-966-7830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D0481682291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX690003975OtherRAILROAD MEDICARE
TX127290803Medicaid
TX690003975OtherRAILROAD MEDICARE