Healthcare Provider Details

I. General information

NPI: 1992119127
Provider Name (Legal Business Name): ALLIED PATHOLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2014
Last Update Date: 06/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 S GREENRIDGE DR
LIBERTY LAKE WA
99019-9566
US

IV. Provider business mailing address

PO BOX 727
LIBERTY LAKE WA
99019-0727
US

V. Phone/Fax

Practice location:
  • Phone: 509-255-1000
  • Fax:
Mailing address:
  • Phone: 509-255-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number603411100
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number603411100
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number603411100
License Number StateWA

VIII. Authorized Official

Name: DR. GERALDINE PETERDY
Title or Position: PRESIDENT
Credential: MD
Phone: 509-255-1000