MEDICARE: MID-AMERICA PATHOLOGY SERVICES INC

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	15D0935056	IN

General Provider Information

NPI Number	:	1902115314
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MID-AMERICA PATHOLOGY SERVICES INC

Provider Business Mailing Address
First Line	:	2113 E 62ND ST
Second Line	:	STE 219
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-2311
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3755 E 82ND ST
Second Line	:	STE 75A
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240-7335
Country	:	US
Telephone Number	:	877-476-8522
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	GRAHAM M CORMACK
Credential	:	M.D.
Telephone Number	:	866-446-8708

Provider Enumeration Date	:	10/03/2010
Last Update Date	:	10/07/2010

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