Healthcare Provider Details

I. General information

NPI: 1043308810
Provider Name (Legal Business Name): SANTA FE PATHOLOGY SERVICES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 ST MICHAELS DRIVE
SANTA FE NM
87505-7621
US

IV. Provider business mailing address

465 ST MICHAELS DRIVE SUITE 115
SANTA FE NJ
87505-7621
US

V. Phone/Fax

Practice location:
  • Phone: 505-986-8620
  • Fax: 505-820-2461
Mailing address:
  • Phone: 505-986-8620
  • Fax: 505-820-2461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. HERBERT CLARK ANDERSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 505-820-5399