Healthcare Provider Details

I. General information

NPI: 1578960043
Provider Name (Legal Business Name): BESTGATE PATHOLOGY LAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2014
Last Update Date: 12/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 BESTGATE RD SUITE 2A
ANNAPOLIS MD
21401-3404
US

IV. Provider business mailing address

820 BESTGATE RD SUITE 2B
ANNAPOLIS MD
21401-3404
US

V. Phone/Fax

Practice location:
  • Phone: 410-224-2118
  • Fax: 410-224-2118
Mailing address:
  • Phone: 410-224-2116
  • Fax: 410-224-4960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number21D0219800
License Number StateMD

VIII. Authorized Official

Name: MRS. BRENDA M BOSMA
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 443-837-2011