Provider Demographics
NPI:1548322464
Name:JACKSON PATHOLOGY ASSOCIATES, PC
Entity type:Organization
Organization Name:JACKSON PATHOLOGY ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:DIETERLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:517-788-4951
Mailing Address - Street 1:205 N EAST AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1753
Mailing Address - Country:US
Mailing Address - Phone:517-788-4951
Mailing Address - Fax:
Practice Address - Street 1:205 N EAST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1753
Practice Address - Country:US
Practice Address - Phone:517-788-4951
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1006045OtherINGHAM HEALTH PLAN
MI0C86006OtherBLUE CROSS BLUE SHIELD MI
MI104757OtherPREFERRED CHOICES
MIXX05469OtherHEALTHPLUS OF MI
MI134848800OtherFEDERAL BLACK LUNG
MI37102OtherCOMMUNITY CHOICE OF MI
MIM011703OtherUNITED MINE WORKERS
MI1006045OtherJACKSON COUNTY HEALTHPLAN
MI13484880OtherUS DEPT OF LABOR WORKCOMP
MICN1205OtherRAILROAD MEDICARE
MI029604OtherMIDWEST HEALTH PLAN
MI128395OtherSELECTCARE
MILP380001OtherM-CARE
MI=========050OtherCOMMUNITY CHOICE OF MI