MEDICARE: PATHWAY GENOMICS CORPORATION

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	CLF 338038	CA

General Provider Information

NPI Number	:	1689818627
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATHWAY GENOMICS CORPORATION

Provider Business Mailing Address
First Line	:	4755 NEXUS CENTER DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-3051
Country	:	US
Telephone Number	:	858-450-6600
Fax Number	:	858-866-9751

Provider Business Practice Location Address
First Line	:	4755 NEXUS CENTER DRIVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92121
Country	:	US
Telephone Number	:	858-450-6600
Fax Number	:	858-866-9751

Authorized Official
Title or Position	:	CEO
Name	:	VADIM SHULMAN
Credential	:
Telephone Number	:	858-450-6600

Provider Enumeration Date	:	04/21/2009
Last Update Date	:	08/01/2018

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