=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942223029
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | METROPLEX PATHOLOGY ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2006
-----------------------------------------------------
Last Update Date | 02/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1111 S FREEPORT PKWY
-----------------------------------------------------
City | COPPELL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75019-4435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-979-8292
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6655 NORTH MACARTHUR BLVD ATTN: PROVIDER ENROLLMENT
-----------------------------------------------------
City | IRVING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75039-2443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-596-7031
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP. GENERAL MANAGER
-----------------------------------------------------
Name | RAYMOND CHRISTOPHER WICKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-477-4402
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------