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General NPI Number Information
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NPI Number | 1285618447
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Entity Type | Organization
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Legal Business Name | PATHOLOGY LABORATORY, P.C.
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Dates
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Enumeration Date | 12/01/2005
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Last Update Date | 06/23/2014
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Provider Practice Location Address
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Address Line | 2620 HORIZON DRIVE SE SUITE 100
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City | GRAND RAPIDS
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State | MI
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Zip | 49546-7936
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Country | US
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Telephone | 616-530-3344
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Fax | 616-530-0575
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Provider Business Mailing Address
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Address Line | 2620 HORIZON DR SE SUITE 100
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City | GRAND RAPIDS
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State | MI
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Zip | 49546-7520
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Country | US
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Telephone | 616-530-3344
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Fax | 616-530-0575
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KIM A. MILLS
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Credential | M.D.
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Telephone | 616-530-3344
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ZP0102X
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Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
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License Number | 23D0380021
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 23D0380021
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License Number State | MI
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