Healthcare Provider Details

I. General information

NPI: 1750580510
Provider Name (Legal Business Name): PARKWAY PATHOLOGY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 10/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 SAPPINGTON BRIDGE RD ATTN: PATHOLOGY DEPARTMENT
SULLIVAN MO
63080-2354
US

IV. Provider business mailing address

PO BOX 500720
SAINT LOUIS MO
63150-0720
US

V. Phone/Fax

Practice location:
  • Phone: 573-468-4186
  • Fax:
Mailing address:
  • Phone: 314-989-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: CHARLES SHORT
Title or Position: PRESIDENT
Credential: MD
Phone: 314-996-4285