MEDICARE: CENTURY PATHOLOGY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory	K9353	TX

General Provider Information

NPI Number	:	1093017840
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTURY PATHOLOGY, LLC

Provider Business Mailing Address
First Line	:	1415 NORTH LOOP W
Second Line	:	SUITE 1200
City	:	HOUSTON
State	:	TX
Zip	:	77008-1664
Country	:	US
Telephone Number	:	713-589-6879
Fax Number	:	713-795-5081

Provider Business Practice Location Address
First Line	:	9150 S MAIN ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77025-3843
Country	:	US
Telephone Number	:	713-589-6879
Fax Number	:

Authorized Official
Title or Position	:	REVENUE MANAGER
Name	:	CYNTHIA DAVIS
Credential	:
Telephone Number	:	713-589-6879

Provider Enumeration Date	:	11/30/2010
Last Update Date	:	11/30/2010

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