Provider Demographics
NPI:1306916937
Name:BOLIVAR PATHOLOGY SERVICES
Entity type:Organization
Organization Name:BOLIVAR PATHOLOGY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PATHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:G
Authorized Official - Last Name:SPARACINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-573-2307
Mailing Address - Street 1:PO BOX 98535
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27624-8535
Mailing Address - Country:US
Mailing Address - Phone:919-420-7811
Mailing Address - Fax:919-420-7815
Practice Address - Street 1:901 E SUNFLOWER RD
Practice Address - Street 2:901 HWY 8 EAST
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2833
Practice Address - Country:US
Practice Address - Phone:662-846-5689
Practice Address - Fax:662-846-2244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16044291U00000X, 171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSH10841Medicare UPIN