Healthcare Provider Details

I. General information

NPI: 1306032891
Provider Name (Legal Business Name): SOUTHWESTERN PATHOLOGY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4704 NW MOTIF MANOR BLVD SUITE 7
LAWTON OK
73505-4800
US

IV. Provider business mailing address

4704 NW MOTIF MANOR BLVD SUITE 7
LAWTON OK
73505-4800
US

V. Phone/Fax

Practice location:
  • Phone: 580-536-0021
  • Fax: 580-536-1024
Mailing address:
  • Phone: 580-536-0021
  • Fax: 580-536-1024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number19385
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number19385
License Number StateOK

VIII. Authorized Official

Name: DR. MICHAEL C MCGINNIS
Title or Position: DIRECTOR OF PATHOLOGY/OWNER
Credential: M.D.
Phone: 580-536-0021