Healthcare Provider Details

I. General information

NPI: 1275740987
Provider Name (Legal Business Name): OUTPATIENT CYTOPATHOLOGY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 05/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 SUSANNAH ST SUITE A
JOHNSON CITY TN
37601
US

IV. Provider business mailing address

PO BOX 2484
JOHNSON CITY TN
37605-2484
US

V. Phone/Fax

Practice location:
  • Phone: 423-283-4734
  • Fax: 423-283-4736
Mailing address:
  • Phone: 423-283-4734
  • Fax: 423-283-4736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License NumberMD020455
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number
License Number State

VIII. Authorized Official

Name: SUSAN D ROLLINS
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 423-283-4734