Healthcare Provider Details

I. General information

NPI: 1386717940
Provider Name (Legal Business Name): CUTANEOUS AND MAXILLOFACIAL PATHOLOGY LABORATORY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 06/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9292 N. MERIDIAN ST. SUITE 210
INDIANAPOLIS IN
46260-1828
US

IV. Provider business mailing address

9292 N. MERIDIAN ST. SUITE 210
INDIANAPOLIS IN
46260-1828
US

V. Phone/Fax

Practice location:
  • Phone: 317-843-2204
  • Fax: 317-843-2478
Mailing address:
  • Phone: 317-843-2204
  • Fax: 317-843-2478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number15D0647261
License Number StateIN

VIII. Authorized Official

Name: CHRISTY D. LYNN
Title or Position: BILLING CLERK
Credential:
Phone: 317-843-2204