=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649273459
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HISTOLOGY ASSOCIATES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2005
-----------------------------------------------------
Last Update Date | 08/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22108 HARPER AVE
-----------------------------------------------------
City | SAINT CLAIR SHORES
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48080-1830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-774-4290
-----------------------------------------------------
Fax | 586-774-4220
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10935 COUNTY ROAD 159
-----------------------------------------------------
City | TYLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75703-3333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-805-9955
-----------------------------------------------------
Fax | 903-839-2494
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | ROBERT E. CARPENTER
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 903-805-9955
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZC0006X
-----------------------------------------------------
Taxonomy Name | Clinical Pathology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------