Provider Demographics
NPI:1104981760
Name:AMERIPATH TEXARKANA 501A CORPORATION
Entity type:Organization
Organization Name:AMERIPATH TEXARKANA 501A CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:H
Authorized Official - Last Name:GREENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-932-8270
Mailing Address - Street 1:7111 FAIRWAY DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-4207
Mailing Address - Country:US
Mailing Address - Phone:561-712-6265
Mailing Address - Fax:561-712-7349
Practice Address - Street 1:5409 PLAZA DR
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-1662
Practice Address - Country:US
Practice Address - Phone:903-223-5200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMERIPATH INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-26
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45D0482326291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45D0482326OtherCLIA