Provider Demographics
NPI:1962791509
Name:ADVANCE PATHOLOGY SERVICES P.C.
Entity type:Organization
Organization Name:ADVANCE PATHOLOGY SERVICES P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING/CREDENTIALING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:ROXANNE
Authorized Official - Middle Name:L
Authorized Official - Last Name:DUFORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-775-0374
Mailing Address - Street 1:PO BOX 87
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-0087
Mailing Address - Country:US
Mailing Address - Phone:231-775-0374
Mailing Address - Fax:231-775-0027
Practice Address - Street 1:8865 PROFESSIONAL DR STE 3
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-8424
Practice Address - Country:US
Practice Address - Phone:231-468-2346
Practice Address - Fax:231-468-2349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-05
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301407392291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory