Provider Demographics
NPI:1053530758
Name:PATHADVANTAGE, PA
Entity type:Organization
Organization Name:PATHADVANTAGE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:GILLESPIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-219-5880
Mailing Address - Street 1:5327 N CENTRAL EXPY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-3361
Mailing Address - Country:US
Mailing Address - Phone:214-219-5880
Mailing Address - Fax:214-219-5881
Practice Address - Street 1:5327 N CENTRAL EXPY
Practice Address - Street 2:SUITE 300
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75205-3361
Practice Address - Country:US
Practice Address - Phone:214-219-5880
Practice Address - Fax:214-219-5881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX220033145OtherMCARE RR
TX00205TMedicare PIN