Healthcare Provider Details

I. General information

NPI: 1285618447
Provider Name (Legal Business Name): PATHOLOGY LABORATORY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 06/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 HORIZON DRIVE SE SUITE 100
GRAND RAPIDS MI
49546-7936
US

IV. Provider business mailing address

2620 HORIZON DR SE SUITE 100
GRAND RAPIDS MI
49546-7520
US

V. Phone/Fax

Practice location:
  • Phone: 616-530-3344
  • Fax: 616-530-0575
Mailing address:
  • Phone: 616-530-3344
  • Fax: 616-530-0575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number23D0380021
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number23D0380021
License Number StateMI

VIII. Authorized Official

Name: DR. KIM A. MILLS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 616-530-3344