Provider Demographics
NPI:1528155793
Name:BLUEWATER PATHOLOGY PC
Entity type:Organization
Organization Name:BLUEWATER PATHOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:T
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-989-3270
Mailing Address - Street 1:1221 PINE GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3511
Mailing Address - Country:US
Mailing Address - Phone:810-989-3270
Mailing Address - Fax:
Practice Address - Street 1:1221 PINE GROVE AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3511
Practice Address - Country:US
Practice Address - Phone:810-989-3270
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104673OtherCARE CHOICES
MI0G46251OtherBLUE CROSS BLUE SHIELD
MI1541762OtherUNITED MINEWORKERS
MI104673OtherPREFERRED CHOICES
MIXX32047OtherHEALTHPLUS OF MI
MI027930OtherMIDWEST HEALTH PLAN
MI1008856 0001OtherTHE WELLNESS PLAN
MICH5571OtherRAILROAD MEDICARE
MI34155OtherCOMMUNITY CHOICE OF MI
MI34155OtherCOMMUNITY CHOICE OF MI