Provider Demographics
NPI:1902115314
Name:MID-AMERICA PATHOLOGY SERVICES INC
Entity Type:Organization
Organization Name:MID-AMERICA PATHOLOGY SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GRAHAM
Authorized Official - Middle Name:M
Authorized Official - Last Name:CORMACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:866-446-8708
Mailing Address - Street 1:2113 E 62ND ST
Mailing Address - Street 2:STE 219
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-2311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3755 E 82ND ST
Practice Address - Street 2:STE 75A
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-7335
Practice Address - Country:US
Practice Address - Phone:877-476-8522
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-03
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN15D0935056291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory