Healthcare Provider Details

I. General information

NPI: 1275589624
Provider Name (Legal Business Name): DERMATOPATH LAB, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 12/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 PLEASANT ST SUITE 106
ATTLEBORO MA
02703-2400
US

IV. Provider business mailing address

555 PLEASANT ST SUITE 106
ATTLEBORO MA
02703-2400
US

V. Phone/Fax

Practice location:
  • Phone: 508-226-5540
  • Fax: 508-226-9619
Mailing address:
  • Phone: 508-226-5540
  • Fax: 508-226-9619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number2413
License Number StateMA

VIII. Authorized Official

Name: YVONNE C. HINES
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 508-226-5540