Healthcare Provider Details

I. General information

NPI: 1649873647
Provider Name (Legal Business Name): MARLBORO CHESTERFIELD PATHOLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2020
Last Update Date: 11/20/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PAGE ST
PINEHURST NC
28374-7928
US

IV. Provider business mailing address

PO BOX 4270
PINEHURST NC
28374-4270
US

V. Phone/Fax

Practice location:
  • Phone: 910-687-4188
  • Fax: 910-235-0171
Mailing address:
  • Phone: 910-687-4189
  • Fax: 910-235-0171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CYNTHIA DAWN QUICK
Title or Position: BILLING
Credential:
Phone: 910-687-4189