Provider Demographics
NPI:1538552500
Name:DERMATOPATHOLOGY LABORATORY OF CENTRAL STATES - MICHIGAN
Entity type:Organization
Organization Name:DERMATOPATHOLOGY LABORATORY OF CENTRAL STATES - MICHIGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MACKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-312-3826
Mailing Address - Street 1:7835 PARAGON RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4021
Mailing Address - Country:US
Mailing Address - Phone:800-532-3232
Mailing Address - Fax:800-840-0819
Practice Address - Street 1:1100 OWENDALE DR
Practice Address - Street 2:SUITE A
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-1914
Practice Address - Country:US
Practice Address - Phone:800-592-5192
Practice Address - Fax:248-519-1047
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DERMATOPATHOLOGY LABORATORY OF CENTRAL STATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-14
Last Update Date:2015-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI6067Medicare PIN