MEDICARE: EAST TEXAS PATHOLOGY LABORATORIES

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	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	J2242	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0085PV	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1942437116
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST TEXAS PATHOLOGY LABORATORIES

Provider Business Mailing Address
First Line	:	PO BOX 730
Second Line	:
City	:	CADDO MILLS
State	:	TX
Zip	:	75135-0730
Country	:	US
Telephone Number	:	903-675-0080
Fax Number	:

Provider Business Practice Location Address
First Line	:	134 ROSEDALE DR
Second Line	:
City	:	ATHENS
State	:	TX
Zip	:	75751-3625
Country	:	US
Telephone Number	:	903-675-0080
Fax Number	:

Authorized Official
Title or Position	:	VP OPERATIONS
Name	:	MELISSA YARBROUGH
Credential	:
Telephone Number	:	214-536-5634

Provider Enumeration Date	:	06/16/2009
Last Update Date	:	06/18/2009

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Directions to “EAST TEXAS PATHOLOGY LABORATORIES ” Practice Location

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