Healthcare Provider Details

I. General information

NPI: 1669882478
Provider Name (Legal Business Name): AMERICAN DERMATOPATHOLOGY LABORATORY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2014
Last Update Date: 04/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210A E SPRING VALLEY PIKE
DAYTON OH
45458-2653
US

IV. Provider business mailing address

210A E SPRING VALLEY PIKE
DAYTON OH
45458-2653
US

V. Phone/Fax

Practice location:
  • Phone: 937-412-4230
  • Fax: 937-482-0542
Mailing address:
  • Phone: 937-412-4230
  • Fax: 937-482-0542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number
License Number State

VIII. Authorized Official

Name: HASSAN NICHOLAS SHAMMA
Title or Position: OWNER
Credential: MD
Phone: 937-602-4322