Provider Demographics
NPI:1831236652
Name:PATH LAB OF MIDDLE TENNESSEE
Entity type:Organization
Organization Name:PATH LAB OF MIDDLE TENNESSEE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:MICHAELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-396-4489
Mailing Address - Street 1:PO BOX 1069
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:TN
Mailing Address - Zip Code:37116-1069
Mailing Address - Country:US
Mailing Address - Phone:615-868-1266
Mailing Address - Fax:615-868-1316
Practice Address - Street 1:400 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37130-3837
Practice Address - Country:US
Practice Address - Phone:615-396-4489
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN25282174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN2006591OtherBLUE CROSS
TN220015692OtherRAILROAD MEDICARE
TN3032197Medicaid
TN3083843Medicaid
TN220015757OtherRAILROAD MEDICARE
TN3049004OtherBLUE CROSS
TN3705607Medicare ID - Type UnspecifiedMEDICARE GROUP
TN3083843Medicaid
TNE97895Medicare UPIN