Provider Demographics
NPI:1285618447
Name:PATHOLOGY LABORATORY, P.C.
Entity type:Organization
Organization Name:PATHOLOGY LABORATORY, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:A
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:616-530-3344
Mailing Address - Street 1:2620 HORIZON DR SE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7520
Mailing Address - Country:US
Mailing Address - Phone:616-530-3344
Mailing Address - Fax:616-530-0575
Practice Address - Street 1:2620 HORIZON DRIVE SE
Practice Address - Street 2:SUITE 100
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-7936
Practice Address - Country:US
Practice Address - Phone:616-530-3344
Practice Address - Fax:616-530-0575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-01
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI23D0380021207ZP0102X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP30660Medicare PIN