Provider Demographics
NPI:1871593293
Name:MOLECULAR PATHOLOGY SERVICES OF THE HENRY VOGT CANCER RESEARCH INST
Entity type:Organization
Organization Name:MOLECULAR PATHOLOGY SERVICES OF THE HENRY VOGT CANCER RESEARCH INST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERIM DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:SLONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-852-0029
Mailing Address - Street 1:529 S JACKSON ST
Mailing Address - Street 2:STE 417
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-3229
Mailing Address - Country:US
Mailing Address - Phone:502-852-7093
Mailing Address - Fax:502-852-0886
Practice Address - Street 1:529 S JACKSON ST
Practice Address - Street 2:STE 417
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3229
Practice Address - Country:US
Practice Address - Phone:502-852-7093
Practice Address - Fax:502-852-0886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY200191291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65945289Medicaid
KY18D0648486OtherCLIA
KY000000060628OtherANTHEM PROV #
KY1060980OtherPASSPORT PROVIDER #
KY2434185000OtherMEDICARE REPLACEMENT
KY200043080AOtherIN MCD #
KY4013801Medicare PIN
KY1060980OtherPASSPORT PROVIDER #