Healthcare Provider Details

I. General information

NPI: 1285739276
Provider Name (Legal Business Name): PATHOLOGY DIAGNOSTIC SERVICES P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 03/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

377 WOODLAND CIRCLE
LUDLOW MA
01056
US

IV. Provider business mailing address

377 WOODLAND CIRCLE
LUDLOW MA
01056
US

V. Phone/Fax

Practice location:
  • Phone: 401-254-6160
  • Fax: 401-254-6163
Mailing address:
  • Phone: 401-254-6160
  • Fax: 401-254-6163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number32284
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number32284
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number32284
License Number StateMA

VIII. Authorized Official

Name: DR. GEORGE HENRY HOLSTEN III
Title or Position: CEO
Credential: M.D.
Phone: 401-254-1006