Provider Demographics
NPI:1427424993
Name:ADVANCED PATHOLOGY LABORATORY LLC
Entity type:Organization
Organization Name:ADVANCED PATHOLOGY LABORATORY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-819-6417
Mailing Address - Street 1:13 CORPORATE BLVD NE STE 250
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30329-1901
Mailing Address - Country:US
Mailing Address - Phone:516-457-1806
Mailing Address - Fax:
Practice Address - Street 1:315 MESEROLE ST STE B3
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-1765
Practice Address - Country:US
Practice Address - Phone:516-457-1806
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-19
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207ZP0105X, 291U00000X
NY181348291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01876580Medicaid