Provider Demographics
NPI:1386717940
Name:CUTANEOUS AND MAXILLOFACIAL PATHOLOGY LABORATORY, PC
Entity type:Organization
Organization Name:CUTANEOUS AND MAXILLOFACIAL PATHOLOGY LABORATORY, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING CLERK
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:D
Authorized Official - Last Name:LYNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-843-2204
Mailing Address - Street 1:9292 N. MERIDIAN ST.
Mailing Address - Street 2:SUITE 210
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1828
Mailing Address - Country:US
Mailing Address - Phone:317-843-2204
Mailing Address - Fax:317-843-2478
Practice Address - Street 1:9292 N. MERIDIAN ST.
Practice Address - Street 2:SUITE 210
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1828
Practice Address - Country:US
Practice Address - Phone:317-843-2204
Practice Address - Fax:317-843-2478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN15D0647261291U00000X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100236370AMedicaid
IN100236370AMedicaid
982630Medicare PIN