Provider Demographics
NPI:1285739276
Name:PATHOLOGY DIAGNOSTIC SERVICES P.C.
Entity type:Organization
Organization Name:PATHOLOGY DIAGNOSTIC SERVICES P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:HOLSTEN
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:401-254-1006
Mailing Address - Street 1:377 WOODLAND CIRCLE
Mailing Address - Street 2:
Mailing Address - City:LUDLOW
Mailing Address - State:MA
Mailing Address - Zip Code:01056
Mailing Address - Country:US
Mailing Address - Phone:401-254-6160
Mailing Address - Fax:401-254-6163
Practice Address - Street 1:377 WOODLAND CIRCLE
Practice Address - Street 2:
Practice Address - City:LUDLOW
Practice Address - State:MA
Practice Address - Zip Code:01056
Practice Address - Country:US
Practice Address - Phone:401-254-6160
Practice Address - Fax:401-254-6163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA32284207ZP0102X, 207ZP0105X, 291U00000X
207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Multi-Specialty
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9760784Medicaid
MA9760784Medicaid
MAS100150179Medicare PIN