Provider Demographics
NPI:1306868427
Name:GRAND TRAVERSE PATHOLOGY, PLLC
Entity type:Organization
Organization Name:GRAND TRAVERSE PATHOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:W
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-935-6108
Mailing Address - Street 1:PO BOX 9099
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75608-9099
Mailing Address - Country:US
Mailing Address - Phone:903-663-4800
Mailing Address - Fax:419-223-2726
Practice Address - Street 1:1105 6TH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2345
Practice Address - Country:US
Practice Address - Phone:231-935-0499
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI510047OtherPREFERRED CHOICES
MI820OtherPRIORITY HEALTH
MICB1092OtherRAILROAD MEDICARE
MI0B87602OtherBCBS
MI36478OtherCOMMUNITY CHOICE OF MI
MI018175OtherMIDWEST HEALTH PLAN
MI53481AOtherHEALTH ALLIANCE PLAN
MIXX01516OtherHEALTHPLUS
MI018175OtherMIDWEST HEALTH PLAN
MI53481AOtherHEALTH ALLIANCE PLAN