=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033108519
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAWD PATHOLOGY GROUP PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2005
-----------------------------------------------------
Last Update Date | 07/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9705 LENEXA DR
-----------------------------------------------------
City | LENEXA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66215-1345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-396-8509
-----------------------------------------------------
Fax | 913-495-9743
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9705 LENEXA DR
-----------------------------------------------------
City | LENEXA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66215-1345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-396-8509
-----------------------------------------------------
Fax | 913-495-9743
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL MANAGER
-----------------------------------------------------
Name | JEFF W WILSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 913-396-8509
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number | 26D0652254
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------