MEDICARE: PREMIER PATHOLOGY LAB, 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

General Provider Information

NPI Number	:	1700286135
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER PATHOLOGY LAB, LLC

Provider Business Mailing Address
First Line	:	19073 NORTH I-45 FWY STE 145
Second Line	:
City	:	SHENANDOAH
State	:	TX
Zip	:	77385-8744
Country	:	US
Telephone Number	:	936-231-8027
Fax Number	:	281-476-7798

Provider Business Practice Location Address
First Line	:	230 ED ENGLISH DR UNIT D
Second Line	:
City	:	SHENANDOAH
State	:	TX
Zip	:	77385-8744
Country	:	US
Telephone Number	:	936-231-8027
Fax Number	:	281-476-7798

Authorized Official
Title or Position	:	OWNER
Name	:	DR. THINH PHAN
Credential	:	M.D.
Telephone Number	:	888-416-8118

Provider Enumeration Date	:	09/04/2014
Last Update Date	:	07/15/2015

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