Healthcare Provider Details

I. General information

NPI: 1023253192
Provider Name (Legal Business Name): MAWD PATHOLOGY GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2008
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9705 LENEXA DR
LENEXA KS
66215-1345
US

IV. Provider business mailing address

9705 LENEXA DR
LENEXA KS
66215-1345
US

V. Phone/Fax

Practice location:
  • Phone: 913-396-8509
  • Fax: 913-495-9743
Mailing address:
  • Phone: 913-396-8509
  • Fax: 913-495-9743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number26D0652254
License Number StateMO

VIII. Authorized Official

Name: JEFF W WILSON
Title or Position: GENERAL MANAGER
Credential:
Phone: 913-396-8509