Healthcare Provider Details

I. General information

NPI: 1023263647
Provider Name (Legal Business Name): PACIFIC PATHOLOGY ASSOCIATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2008
Last Update Date: 07/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 WINTER ST SE
SALEM OR
97301-3934
US

IV. Provider business mailing address

PO BOX 6930
PORTLAND OR
97228-6930
US

V. Phone/Fax

Practice location:
  • Phone: 503-561-5350
  • Fax: 419-866-5453
Mailing address:
  • Phone: 503-561-5350
  • Fax: 419-866-5453

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 Number38D1091741
License Number StateOR

VIII. Authorized Official

Name: CLARK MCDONALD
Title or Position: PRESIDENT
Credential:
Phone: 503-561-5350