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NPI Code Detail

MEDICARE: WEST SUBURBAN PATHOLOGY CONSULTANTS PA

MEDICARE: WEST SUBURBAN PATHOLOGY CONSULTANTS PA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207ZP0102XAnatomic Pathology & Clinical Pathology Physician

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
118722WEOTHERMNBLUE SHIELD

General Provider Information

NPI Number : 1902865611
Entity Type Code : Organization
Provider Name (Legal Business Name) : WEST SUBURBAN PATHOLOGY CONSULTANTS PA
Provider Business Mailing Address
First Line : PO BOX 385760
Second Line :
City : BLOOMINGTON
State : MN
Zip : 55438-5760
Country : US
Telephone Number : 952-944-0970
Fax Number :
Provider Business Practice Location Address
First Line : 6500 EXCELSIOR BLVD
Second Line :
City : MINNEAPOLIS
State : MN
Zip : 55426-4702
Country : US
Telephone Number : 952-993-5290
Fax Number :
Authorized Official
Title or Position : SECRETARY/TREASURER
Name : DR. MATTHEW DALY MCCOY
Credential : MD
Telephone Number : 952-993-5290
Provider Enumeration Date : 03/21/2006
Last Update Date : 09/12/2007

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