Provider Demographics
NPI:1205997889
Name:PACIFIC PATHOLOGY ASSOCIATES, INC.
Entity type:Organization
Organization Name:PACIFIC PATHOLOGY ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-561-5564
Mailing Address - Street 1:5700 SOUTHWYCK BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-1509
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:419-866-5453
Practice Address - Street 1:665 WINTER ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3934
Practice Address - Country:US
Practice Address - Phone:503-561-5350
Practice Address - Fax:503-561-4781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR38D0625543291U00000X
207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR006465Medicaid
OR0000WCJWBMedicare ID - Type Unspecified