NPIMap

Organization Active NPI

Pathology Services Laboratory PA

  • Clinical Medical Laboratory
  • Russellville, AR
National Provider Identifier
1093889347
Registry record updated May 31, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical Medical LaboratoryTaxonomy code 291U00000X
Legal business name
PATHOLOGY SERVICES LABORATORY PA
Practice address
1430 West C Street
Russellville, AR 72811-0925
Phone
(479) 968-6781
Fax
(479) 968-3074
NPI assigned
Nov 20, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 31, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Christina Ann Jetton, M.D.
Title
President
Phone
(479) 968-6781

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Anatomic Pathology & Clinical Pathology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207ZP0102X
Clinical Medical Laboratory 291U00000X Primary

Addresses

Primary practice location

1430 West C Street
Russellville, AR 72811-0925

Mailing address

PO Box 925
Russellville, AR 72811-0925
Phone (479) 968-6781

Other identifiers 3

IdentifierTypeStateIssuer
103882709MedicaidAR
MC0330OtherARLICENSE NUMBER
770091902OtherBREASTCARE

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20080228000774 AR Part B Supplier - Independent Clinical Laboratory 0840373411 Practice locations: Russellville, AR

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1163980800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1717113600000",
    "number": "1093889347",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 925",
            "city": "RUSSELLVILLE",
            "state": "AR",
            "postal_code": "728110925",
            "telephone_number": "479-968-6781",
            "fax_number": "479-968-3074"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1430 WEST C STREET",
            "city": "RUSSELLVILLE",
            "state": "AR",
            "postal_code": "728110925",
            "telephone_number": "479-968-6781",
            "fax_number": "479-968-3074"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PATHOLOGY SERVICES LABORATORY PA",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-20",
        "last_updated": "2024-05-31",
        "certification_date": "2024-05-31",
        "status": "A",
        "authorized_official_last_name": "JETTON",
        "authorized_official_first_name": "CHRISTINA",
        "authorized_official_middle_name": "ANN",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "479-968-6781",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207ZP0102X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pathology, Anatomic Pathology & Clinical Pathology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "103882709",
            "state": "AR"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LICENSE NUMBER",
            "identifier": "MC0330",
            "state": "AR"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BREASTCARE",
            "identifier": "770091902",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Russellville, AR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 31, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.